Avantara Norton

Inspectors wroteBased on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI) report, interview, record review, and policy review, the provider failed to follow professional nursing standards regarding following physicians orders timely for one of one sampled resident (112) who was not administered antibiotic medications as ordered and notifying the physician about one of one sampled resident (88), who complained of feeling dizzy after receiving dialysis (a treatment that removes waste products and excess fluid from blood when the kidneys are unable to) that the resident was not consistently administered his blood pressure medication as ordered or of his low blood pressures.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, SD DOH complaint intake report, record review, observation, interview, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) prevention interventions for one of one sampled resident (16) identified with risk for developing pressure ulcers who developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer on her left buttock and one of one sampled resident (9) with a history of pressure ulcer and identified with risk for developing pressure ulcer who developed a stage III (3; [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure resident safety and accident prevention when:*A staff member safely transferred one of one sampled resident (53), who needed to be transferred with the use of a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) according to that resident's care plan by one of one certified nursing assistant (CNA) VV, who attempted to transfer the resident without using the stand lift. [...]

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to assess and manage pain for one of one sampled resident (78) who showed signs of having pain.

Inspectors wroteBased on interview, record review, observation, and policy review, the provider failed to ensure one of one registered nurse (RN) (F) administered a medication according to the physician's order for one of one sampled resident (44) with a history of heart disease who required the use of the medication to prevent chest pain.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to support the residents' right to choose and receive the frequency of bathing consistent with their preferences for four of thirty-four sampled residents (16, 36, 61, and 77) who preferred to receive bathing at least twice a week.

Inspectors wroteBased on record review, interview, and Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure five of six sampled residents' (2, 8, 36, 41, and 49) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of Pre-admission Screening and Resident Review (a mandatory federal process that ensures people with mental illness or intellectual disabilities are not inappropriately placed in nursing homes)(PASRR), insulin administration, and prescribed psychotropic medications (drugs that affect brain activities associated with mental processes and behavior).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was completed within 48 hours of the resident's admission to the facility for three of nine sampled residents (2, 6, and 98), and was reviewed with, and a copy was offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for seven of nine newly admitted sampled residents (2, 6, 30, 36, 44, 61, and 98).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure an ongoing restorative nursing program was completed according to the residents' care planned needs for two of two sampled residents (40 and 43) at risk for a decline in range of motion.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, record review, interview, and policy review, the provider failed to protect the residents' right to dignity and privacy for two of two observed sampled residents (16 and 74) with soiled clothing and unclean hands and faces, and one of one observed sampled resident (3) not provided privacy while receiving personal care in his shared room by two of two observed certified nursing assistants (CNA) (N and Q).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the code status (emergent treatment a person wishes to receive if their heart or breathing would stop) for two of two sampled residents (2 and 25) was currently and accurately documented in the residents' electronic medical records (EMR).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) Facility Reported Event (FRI) report, interview, record review, observation, and policy review, the provider failed to protect the resident's right to be free from neglect for one of one sampled resident (15) who was left in the dining room for approximately 10 hours by one of one certified nursing assistant (CNA) (RR) and one of one licensed practical nurse (LPN) (SS) without receiving identified interventions to meet his care needs.

Inspectors wroteBased South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff followed the care planned interventions for one of one sampled resident (72) identified as requiring all of her care to be provided by two caregivers who expressed distress and reported that one of one certified nursing assistant (CNA) (JJ) was rough with the resident when that CNA did not provide the resident's care with another staff member present. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure one of one observed dietary aide (DA) (EE) washed her hands after touching her face, hair, and pants, washed her hands for the required amount of time, wore gloves before handling resident's food, and replaced a milk jug lid after it fell on the floor in one of three dining rooms (Central).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection control practices regarding:*Hand hygiene (handwashing or hand sanitizer use) and glove use by two of two housekeepers (DD and HH) while cleaning residents' rooms.*Manufacturer's recommended chemical contact time (the duration a disinfectant must remain visibly wet on a surface to effectively kill pathogens) was followed by two of two housekeepers (DD and HH) while cleaning residents' rooms.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure residents received quality care when one of one certified nurse aide (CNA) N applied Nair (chemical hair removal cream) cream to one of one sampled resident's (2) peri area (perineum, the skin between the genitals and anus) who did not have a physician's order for use of that cream and subsequently sustained a chemical skin burn. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint report review, record review, observation, interview, and policy review, the provider failed to monitor and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (1) who admitted to the facility with a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) that worsened and who developed a pressure ulcer to her right ankle.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the staff safely transferred a resident according to the resident's care plan for one of one sampled resident (4) who needed to be transferred with the assistance of two staff members by one of one certified nursing assistant (CNA)(P) who attempted to transfer the resident without the assistance of another staff member. That failure resulted in the resident having pain in her left knee and sustaining two skin tears to her left leg.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of two of two sampled residents (2 and 3) who eloped (left the facility without staff knowledge) from the front door of the facility on 7/26/25 and 9/12/25. Both residents had been mistaken for visitors at the time of their elopements. The facility's front door alarm system had been bypassed during the elopements by using an employee's badge.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, policy review, observation, interview, and record review, the provider failed to ensure that one of one employee (cook J) served food at a safe temperature, according to the provider's policy, which potentially led to one of one resident (4) having skin redness after spilling soup on himself. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure staff members followed infection prevention practices for:*Personal protective equipment (PPE) use by one of one observed certified nursing assistant (CNA) D when providing care for five of five sampled residents (1, 2, 3, 4, and 5) on enhanced barrier precautions (use of gown and gloves while providing contact care)(EBP).*Cleaning shared-use equipment, specifically lift devices, after each resident's use by one of one CNA D.*Maintaining a clean environment in one of one sampled resident (6) room who reported spilled urine that remained on the floor for about two hours.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (3) with a pressure ulcer received the necessary dressing changes as ordered and interventions according to the resident's care plan to prevent his ulcer and infection from worsening. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, review of call light log, review of personnel file, interviews and policy review, the provider failed to protect the resident's right to be free from neglect for one of one sampled resident (2) who waited for staff assistance for more than an hour after turning on his call light. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure professional nursing standards of practice regarding medication administration were followed by licensed practical nurse (LPN) (F) who administered one of one sampled resident'(4) another resident's medications. That failure resulted in medication errors.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview and policy review, the provider failed to protect the safety of one of one sampled resident (1) identified as at risk for elopement (leaving the facility without staff knowledge). Who was assisted out of the building by certified nursing assistant (CNA) H who left the facility property and resident 1 remained outside unsupervised. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.

Inspectors wroteA. Based on record review, interview, and policy review, the provider failed to follow professional standards by not having ensured two of two sampled residents (1 and 2) had received their PRN (as needed) controlled (medications with risk for abuse and addiction) pain medications as ordered by the physician.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure two of two sampled residents' (1 and 2) prescribed controlled (medications with risk for abuse and addiction) pain medications were not diverted (when prescribed medication is obtained or used illegally by another person) by one registered nurse (RN) (E). Failure to ensure prevention of diversion of those medications had the potential to cause those residents increased pain and potentially placed all residents' safety at risk who were under RN E's care. This citation is considered past non-compliance based on the provider's identification of the potential diversion and actions implemented following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint report, record review, interview, and policy review, the provider failed to ensure one of one sampled resident (3) had received discharge instructions and education on the risks versus benefits prior to leaving against medical advice (AMA).

Inspectors wroteBased on observation, interview, record review, resident council interview, and policy review, the provider failed to ensure prompt response to call lights and necessary care and services were provided for eight sampled residents (4, 6, 12, 47, 51, 64, 65, and 349) and four additional council meeting residents (3, 10, 61, and 62) to maintain their physical, mental, and emotional well-being. Residents reported frustration, sadness, incontinence, and pain related to the delay in staff's response to their call lights and requests for assistance.

Inspectors wroteBased on record review and interview, the provider failed to ensure the proper Medicare notices were filled out completely and were in the required format for three of three sampled residents (12, 13, and 354) prior to their discharge from Medicare Part A skilled services.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure proper infection control practices had been followed for six of six sampled residents (6,12,22,32,54, and 62) who required respirator devices had appropriate cleaning, storage, and replacement of those devices. 1. Observation and interview on 2/25/25 at 6:49 a.m. with resident 54 in his room revealed: *There was an oxygen concentrator at his bedside. *There was a continuous positive airway pressure (CPAP) machine (a machine to treat sleep-related breathing issues) on his bedside table. *He had lived in the facility for about three weeks. *He indicated he wore the oxygen as needed. *He stated he was supposed to wear the CPAP every night, but he had only been using it intermittently at night. *He was admitted to the facility with oxygen and the CPAP. Observation on 2/26/25 at 11:14 a.m. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow acceptable food standards and their policies to ensure refrigerator temperatures were properly maintained and documented for safe food temperatures, food was labeled, stored, and monitored for safe consumption and to prevent potential outbreaks of foodborne illness for thirteen of thirteen observed residents' (1, 6, 18, 19, 22, 36, 37, 44, 49, 50, 63, 65, and 79) personal refrigerators.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered by administrator A, director of nursing (DON) B, assistant director of nursing (ADON) C, and unit managers F and G, in a manner that ensured quality of life and overall well-being for all 94 residents in the facility.

Inspectors wroteBased on observations, interview, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the overall quality of life and well-being for all 94 residents in the facility.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure proper infection control practices had been followed for: *Two of two sampled residents (5 and 70) who had wound dressings changed by two of two observed staff licensed practical nurse/wound nurse (LPN) M and certified nurse practitioner (CNP) CC. *Four of four sampled residents (29,34, 345, and 350) who required Enhanced Barrier Precautions (EBP) (an infection control strategy in nursing homes that expands the use of personal protective equipment (PPE) specifically gowns and gloves, during high contact resident care activities to reduce the transmission of multi-drug-resistant organisms (MDROs). *Four of four sampled residents (5, 6, 35, 37, and 64) who had unlabeled personal care products to identify the correct resident for usages.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure resident care plans reflected the current individualized needs for: *One of one sampled resident (54) who utilized oxygen and a respiratory device. *One of one sampled resident (64) who had his indwelling feeding tube removed. 1. Observation and interview on 2/25/25 at 6:49 a.m. with resident 54 revealed: *An oxygen concentrator (a machine that takes surrounding air and purifies it into breathable oxygen) was at his bedside. *A continuous positive airway pressure (CPAP) machine (a machine to treat sleep-related breathing issues) was on his bedside table. *He had lived in the facility for about three weeks. *He indicated he wore the oxygen as needed. *He stated he was supposed to wear the CPAP every night, but he had only been using it intermittently at night. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow professional standards for medication administration and physician notification regarding the: *Administration of prescribed medication within the scheduled timeframe for one of one sampled resident (349). *Prompt physician notification of one of one sampled resident's (349) significant weight gain. *Prompt physician notification of abnormal vital signs (such as heart rate and blood pressure) and the holding of medications for one of one sampled resident (51).

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review the provider failed to establish and ensure ongoing open communication with the hospice services provider regarding the use of an overlay air mattress (an air-filled mattress placed over a regular non-air mattress) that had been used by one of one sample resident (1).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to protect one of one sampled resident (1) from neglect by certified nursing assistant (CNA) (C) who did not provide timely care, which potentially resulted in the resident being incontinent for an unknown length of time and may have contributed to the resident's development of two skin sores.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interviews with facility staff failed to ensure the safety of one of one sampled resident (1) whose tunneled chest catheter (a thin tube inserted into a vein in the chest, neck, or groin and tunneled under the skin to a large vein near the heart referred to as a central venous catheter (CVC) to allow access to the vein for medication administration) was removed by registered nurse (RN) (C), not trained to safely perform that task.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, and policy review the provider failed to ensure the care plan reflected the current individualized treatment needs for a tunneled chest catheter (a thin tube inserted into a vein in the chest, neck, or groin and tunneled under the skin to a large vein near the heart referred to as a central venous catheter (CVC) to allow access to the vein for medication administration) versus a peripherally inserted central catheter (PICC) inserted into a vein in the upper arm for one of one sampled resident (1).

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint online report, observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (1) had a baseline care plan created that identified her care needs, goals, and interventions within 48 hours of admission.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint online report, observation, interview, and policy review, the provider failed to implement pressure ulcer prevention interventions to prevent the development of pressure ulcers for one of one sampled resident (3).

Inspectors wroteA. Based on South Dakota Department of Health (SD DOH) complaint online report, observation, interview, and policy review, the provider failed to administer medications ordered by the physician for 2 of 2 sampled residents (1 and 2).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint online report, observation, interview, resident council meeting minutes review, and policy review the provider failed to ensure room trays were served at a satisfactory temperature for two of three sampled residents (4 and 6).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to maintain a clean and sanitary foodservice environment on one of one kitchen and two of two kitchenettes and implement safe food storage practices in one of one kitchen.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to honor a resident's refusal to shower and to follow that resident's bathing preferences as directed on their care plan for one of one sampled resident (1). Failure to do so resulted in the resident expressing feelings of anger and mistrust towards a staff member. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to immediately report allegations of abuse experienced by one of one sampled resident (1). Failure to immediately report allegations of abuse delayed the reporting and investigation process, potentially putting residents at risk for further alleged abuse. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteSubstantial compliance was confirmed on 4/14/24 at 3:23 p.m. after a phone interview was conducted with hospice liaison that the numbers for three of the nurse's stations were provided to the hospice provider for faxing physician's orders that would include new medication orders.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint online report, observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident (2) had staff supervision in place to prevent a hot liquid burn. *Two of two sampled residents (2, and 3) had hot liquid safety evaluations completed, were documented accurately, and interventions in place to prevent potential burns from hot liquids.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint online report, record review, interview, and policy review, the provider failed to follow physician orders to provide pain medication before scheduled wound care was completed for one of one sampled resident (1).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure medications were administered at the time they were prepared and by the individual who prepared the medications for one of one sampled resident (4).

Inspectors wroteBased on observation, interview, record review, and review of grievances, the provider failed to ensure staff interactions and services were provided in a manner that maintained a sense of dignity and respect for two of two sampled residents (144 and 252).

Inspectors wroteBased on observation, interview, record review, and grievance policy review, the provider failed to take steps to investigate all allegations reported by two of three sampled residents (144 and 252).

Inspectors wroteA. Based on observation, interview, record review, and policy review, the provider failed to ensure staff were competent to safely use the mechanical lift equipment and provided with accurate information about each resident's transfer equipment needs, including sling size, for eight of twelve sampled residents (1, 9, 24, 32, 33, 77, 79, 244).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure interventions that had been put in place were consistently implemented and documentation was consistent for four of four sampled residents (3, 37, 39, and 193) who developed pressure ulcers after admission to the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure sufficient nursing staff to provide care or complete/accurate documentation for 41 of 54 residents reviewed during the survey (1, 3, 5, 6, 7, 9, 10, 11, 12, 19, 23, 24, 26, 28, 32, 33, 36, 37, 38, 39, 46, 53, 58, 60, 62, 64, 67, 71, 72, 73, 74, 75, 77, 79, 81, 84, 87, 91, 193, 244, and 253). The census of the facility was 95 at the time of the survey. These failures placed residents at risk for unmet care needs and negative outcomes.

Inspectors wroteBased on observation, interview, record review, review of provider policy and Facility Assessment, the provider failed to ensure nursing staff were verified as competent to perform tasks in accordance with the provider's policies prior to performing them and had adequate knowledge and access to resident information to meet resident needs for 41 of 54 residents reviewed during the survey (1, 3, 5, 6, 7, 9, 10, 11, 12, 19, 23, 24, 26, 28, 32, 33, 36, 37, 38, 39, 46, 53, 58, 60, 62, 64, 67, 71, 72, 73, 74, 75, 77, 79, 81, 84, 87, 91, 193, 244, and 253).

Inspectors wroteBased on observation, interview, record review, complaint reviews, and policy review, the provider failed to ensure the facility was operated and administered by administrator A and director of nursing (DON) B, in a manner that ensured the safety and overall well-being of all 95 residents in the facility.

Inspectors wroteBased on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all 95 residents in the facility.

Inspectors wroteBased on interview, observation, resident grievance review, resident council minutes review, kitchen crew meeting minutes review, manager on duty checklist review, and policy review, the provider failed to support residents' choices for 22 of 53 sampled residents (5, 7, 11, 12, 19, 23, 28, 36, 38, 46, 53, 58, 62, 67, 71, 72, 73, 74, 81, 253, and two residents who had discharged prior to the survey) regarding menu options, condiments, beverages, and timely delivery of meal trays to residents who chose to eat in their rooms.

Inspectors wroteBased on interview, observation, review of resident council minutes, a resident council department response form, and policy review, the provider failed to promptly act upon grievances and provide a response for sixteen residents (5, 7, 12, 19, 23, 28, 38, 46, 53, 58, 62, 67, 71, 73, 74, and 81) who reported ongoing grievances regarding meal and snack service and response to call lights.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to notify the Ombudsman regarding transfers initiated by the provider for four of four sampled residents (6, 9, 24, and 91).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to notify the resident or representative regarding the provider's bed-hold policy at the time of transfer for four of four sampled residents (6, 9, 24 and 91).

Inspectors wroteBased on observation, interview, record review and policy review, the provider failed to ensure care plans were revised to adequately address relevant needs and ensure accurate information for 8 of 31 sampled residents (1, 9, 10, 24, 64, 77, 87, 244).

Inspectors wrote2. Interview on 11/6/23 at 3:52 p.m. with DON B revealed: *He agreed resident 193 was to have received eight ounces of a nutritional supplement daily. *Nursing documented the resident received the nutritional supplement. *Nursing documentation was based off of what dietary had documented on the intake record. *The amount of the nutritional supplement and other fluids the resident received were not recorded as separate entries in the intake record. Observation and interview on 11/8/23 at 9:30 a.m. dietary aide (DA) S revealed: *She was documenting the what the residents had eaten and drank. *DA's document the percentage of what was eaten and amount of fluids drank. *The fluids the resident drank included any nutritional supplement they were supposed to receive. *She stated the CNAs document what the assisted dining residents ate and drank. Interview on 11/8/23 at 9:45 a.m. [...]

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure the consultant pharmacist(s) communicated their recommendations to the residents physicians.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure three of three (3, 12, and 33) sampled residents reviewed for unnecessary psychotropic (mood stabilizer) medications had a gradual dose reduction (GDR).

Inspectors wroteBased on interview, observation, review of weekly schedule for dietary, Grievance and Satisfaction Forms, Resident Council Minutes, a Resident Council Department Response Form, minutes of Kitchen Crew Meetings, provider policy, and the Facility Assessment, the provider failed to have sufficient dietary personnel to ensure timely delivery of meal room trays and snacks for twenty residents (5, 7, 11, 12, 19, 23, 28, 36, 38, 46, 53, 58, 62, 67, 71, 73, 74, 81, and two discharged residents) who reported ongoing grievances regarding timely meal and snack services. (Refer to F 809.)

Inspectors wroteBased on interview, review of Resident Council Minutes, Grievance and Satisfaction Forms, Kitchen Crew Meetings minutes, manager on duty documents, and policy review, the provider failed to ensure timely delivery of meal room trays and snacks for nineteen residents (5, 7, 12, 19, 23, 28, 36, 38, 46, 53, 58, 62, 67, 71, 73, 74, 81, and two discharged residents) who reported ongoing grievances regarding timely meal and snack service.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (75) who received dialysis comprehensive care plan included information on his dialysis access, type of diet, and parameters for fluctuations in his weight.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to administer medications according to the physician's order for one of two sampled residents (84) during one of one medication pass with one of one certified medication aide (CMA) PP.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure infection control policies were adhered to with the following: *Appropriate hand hygiene and glove use by five of five certified nursing assistants (CNAs) X, U, I, K, and T during the provision of personal care for three of three sampled residents (9, 25, and 7).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *One of one carpeted wing (300 east) had carpet that was free from multiple stains. *Thirteen of thirty resident bathroom doors (rooms 302, 305, 308, 309, 311, 312, 315, 318, 319, 325, 326, 327, and 328) were free from scratches and gouges to prevent resident injuries.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, interview, record review, and policy review, the provider failed to meet the bathing and toileting needs for 4 of 5 sampled residents (4, 5, 9, and 10).