CMS-Nursing-Home-Full-Deficiencies: cms

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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Link	rowid ▼	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
101	101	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	684	D	1	0	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, and policy review, the provider failed to ensure necessary care and services was provided for two of twelve sampled residents (52 and 56) as evidenced by: Not giving a timely opportunity to use a toilet or commode and not having a repositioning schedule in place to prevent decline for resident 52. Not investigating a skin tear of unknown origin and not providing an ordered as needed treatment to a swollen surgical site for resident 56. Findings include:1. Observation on 5/22/19 at 1:14 p.m. of resident 52 in her room revealed:She was alone in her room sitting in her wheel chair (w/c) with her back to the door. There was an over bed table in front of her with her lunch on it.There was a large wet area on the floor behind her w/c that was yellow colored.There was a bubble cup on the floor.She had gray sweat pants on.Those sweat pants were wet between her legs where she was sitting.The left front hip crease area of her sweat pants were also wet.Observation and interview on 5/22/19 at 1:18 p.m. of resident 52 in her room revealed:Certified nurse aide (CNA) M walked into the room.She noticed the wet area on the floor and to the resident's sweat pants.She stated she had offered to lay her down at approximately 10:00 a.m. so she could change her brief.-The resident had refused.She used her Walkie Talkie to ask for assistance to the room.She left and returned with a mop and bucket.She mopped up the wet area on the floor behind her w/c.She picked the bubble cup up from the floor and put it on her overbed table.She went into the bathroom and without washing her hands she put on gloves.Observation and Interview on 5/22/19 at 1:34 p.m. of resident 52 in her room revealed:CNAs H and I entered the room.CNA I stated that he and another CNA had changed the resident's brief at 11:50 a.m.-She had had a bowel movement (BM).-When asked, CNA I stated that he had documented that brief change.CNA…	2020-09-01
102	102	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	686	H	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to identify and implement individualized interventions to prevent: Facility acquired pressure ulcers from developing for five of five sampled residents (9, 32, 45, 56, and 73). A blister from worsening and becoming a pressure ulcer for one of one sampled resident (62). Findings include: 1. Review of resident 9's medical record revealed: She had been admitted on [DATE]. Her Brief Interview of Mental Status (BIMS) score was three indicating she had severe cognitive impairment. She had been admitted with a right wrist splint and right knee immobilizer. Review of resident 9's skin assessments between 1/15/19 and 5/21/19 revealed on: 1/15/19 she was admitted with a stage three pressure ulcer on her right buttock and a blister on her right rear thigh. 1/29/19 both were healed. 1/30/19 three wounds had been identified: -Unstageable pressure ulcer between right thumb and fore finger. -Stage two blister to the right upper thumb area. -Suspected deep tissue injury to the right lower thumb. 2/5/19 two additional pressure ulcers were identified on her right hand: -Outside of the right little finger. -Back of the right hand. 2/12/19 two additional pressure ulcers were identified on her right outer ankle. -One stage one. -One stage two. 2/19/19 a stage two pressure ulcer was identified on her right inner heel. 2/26/19 all the above pressure injuries were healed. 4/30/19 a stage two pressure ulcer was identified on her left buttock. 5/7/19 Area to left buttock is bigger. Resident has cushion to w/c (wheelchair). Is working with therapy so doesn't always get laid down. 5/14/19 she had completed wound care and an unstagable wound was found on her coccyx. 5/21/19 two new suspected deep tissue injuries were identified. -Left lower heel. -Left upper heel. Review of resident 9's 5/22/19 care plan revealed: *There were no focus, goals, or interventions related to…	2020-09-01
103	103	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	689	D	1	0	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, and policy review, the facility failed to ensure one of one sampled residents (60) who was totally dependant was transferred safely. Findings include: Review of resident 60's 4/25/19 Minimum Data Set (MDS) assessment revealed: She was admitted on [DATE]. Her Brief Interview for Mental Status (BIMS) score was zero indicating her cognition was severely impaired. She required the extensive assistance of two staff for: -Bed mobility. -Dressing. -Toilet use. She was totally dependent on two or more staff for transfers. Interview of 5/21/19 at 8:51 a.m. with resident 60's representative revealed: She felt the lift used to transfer her mother caused pain. There were two men who worked in the evening who would help get her mother to bed. -She could not remember their names. She had asked them to pick her mother up and move her from the chair to the bed and vice versa. She had witnessed them moving her in this manner, without the lift and believed that it was easier on her mother. Interview on 5/22/19 at 3:19 p.m. with certified nursing assistant (CNA) H regarding resident 60 revealed she: Required a full lift transfer. Denied seeing signs or symptoms of pain for the resident during transfer. Denied seeing anyone transfer her without a lift, stating it would be unsafe. Interview on 5/22/19 3:22 p.m. wit CNA I regarding resident 60 revealed he had: Met resident 60's representative. Never seen or heard of anyone transferring her without a lift. Would not transfer the resident without a lift because it would jeopardize his job. Interview of 5/22/19 at 2:41p.m. with the administrator and the director of nursing (DON) regarding resident 60 revealed: They would not be surprised if the family asked for the resident to be transferred without the lift. They would be surprised if the staff would transfer her without the lift. They had not heard of this happening. They did not transfer people without the tot…	2020-09-01
104	104	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	697	D	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow professional standards for pain management for one of one sampled resident (56) who had high pain levels. Findings include: 1. Observation and interview on 5/21/19 at 3:43 p.m. of licensed practical nurse (LPN) J while she changed the surgical site dressing for resident 56 revealed: The resident was moaning and stating aloud she was having pain at her surgical site when LPN J was removing the dressing. LPN J: -Stated Bear with me and continued to remove the dressing. -Thought she had administered pain medication about one hour ago but it must not have been enough. -Did not attempt to loosen the adhering parts of the dressing before pulling it from the resident's skin. -Did not attempt any nonpharmacological methods of pain management. Review of resident 56's medical record revealed she had: Been admitted on [DATE]. A [DIAGNOSES REDACTED]. A recent surgical procedure of (type of surgery). An order to Cleanse wound with wound cleanser, dress with border gauze and apply stockinet to(name of area) every day shift for wound care. As needed pain medications of: -[MEDICATION NAME] Tablet 5 MG ([MEDICATION NAME] HCL) Give 1 tablet by mouth every 4 hours as needed for PAIN SCALE 8-10 OR 4-7 DO NOT EXCEED 60 MG/DAY Hole if RR rate --LPN J had administered the above medication to the resident at 2:20 p.m. -[MEDICATION NAME] Tablet 5 MG ([MEDICATION NAME] HCL) Give 2 tablet by mouth every 4 hours as needed for PAIN SCALE 8-10 OR 4-7 DO NOT EXCEED 60 MG/DAY Hold if RR rate --LPN J had not administered two tablets of the pain medication pretreatment for [REDACTED]. --She did not stop the treatment when the resident was in pain to provide her the additional pain medication. LPN J had administered the lowest dose of [MEDICATION NAME] to the resident for premedication prior to a painful treatment. *LPN J stated the above was her usual practice for resident…	2020-09-01
105	105	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	745	D	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the provider failed to ensure: 1. One of one sampled residents had a complete and documented discharge plan. 2. One of one sampled residents had support in the transition from rehabilitation to long term care. Findings include: 1. Review of resident 9's 5/3/19 Minimum Data Set (MDS) assessment revealed: Her admitted was 4/22/19. Her Brief Interview for Mental Status (BIMS) score was a three indicating she was severely cognitively impaired. Her family participated in the assessment and no discharge expectation was identified. Interview on 5/21/19 at 2:20 p.m. with resident 9's representative revealed: He lived an hour away from the facility and would like for her to be closer. It was hard for him and other family to visit due to the distance. He did not feel he was getting much help from the provider to find a closer placement for her. Interview on 5/23/19 at 10:20 a.m. with the social services designee (SSD) regarding resident 9's discharge plan revealed: She was aware the resident's representative wanted her to be moved to a facility closer to her hometown. She indicated the resident's representative had toured facilities closer to family. -In those tours he had identified facilities that would be a good fit for her. -She had made referrals to those facilities for the resident. She indicated monthly she followed up with the facilities that she had referred the resident to. She agreed she did not have documentation of the referrals. She agreed she did not have documentation of the follow up calls she had made regarding the referrals. She agreed she should have documented the resident's discharge plans. Review of resident 9's 5/21/19 care plan revealed: She required long term care placement. She would like to be transferred to a facility in her hometown to be closer to family. She was on several waiting lists at facilities in her hometown. There was no identifications of which facilities she…	2020-09-01
106	106	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	868	E	0	1	LF7K11	Based on interview, record review, observation, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to residents' care within the facility. Findings include: 1. Interview on 5/23/19 at 11:45 a.m. with the administrator regarding the QAPI program revealed: The committee met monthly. The medical director attended most months She had identified a problem with facility acquired pressure ulcers. -Started an Action Plan but had not fully implemented it. -The action plan had no implementation date or measurable goals. They had not identified all the areas of concern identified during this recertification survey. They had no performance improvement plans (PIP) in place right now. Review of the provider's undated Quality Assurance and Performance Improvement (QAPI) policy revealed: Purpose Statement: Our organizations written QAPI plan provides for our overall quality improvement program. Quality assurance performance improvement principles will drive the decision making within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. Focus areas will include all systems that affect resident and family satisfaction, quality or care and services provided, and all areas that affect the quality of life for persons living and working in our organization. The QAPI committee will review area our organization believes it needs to monitor on a regular basis to assure systems are monitored and sustained to achieve the quality for our organization. Our organization will utilize evidence based practices and data to define our goals and guide our decisions. Our organization will utilize evidence-based practices and data to define our goals and guide our decisions. Comparison data from our corporation, state and national sources will be used to guide decisions. Refer to F550, F656, F684, F…	2020-09-01
107	107	ROLLING HILLS HEALTHCARE	435035	2200 13TH AVE	BELLE FOURCHE	SD	57717	2019-05-23	880	E	0	1	LF7K11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed the ensure infection control practices were followed for: Cleaning of therapy equipment between resident use by one of one certified occupational therapy assistant (COTA) W. Cleaning and sanitizing of equipment between resident use and disposal of single use items by licensed practical nurse (LPN) (J) following wound care for residents 32 and 56. Use of the Micro Kill Bleach wipes had been used effectively for one of one resident (128) by one certified nurse aide (CNA) (V) observed. Catheter bag placement for one of one observed resident (125). Personal protective equipment (PPE) had been used correctly by CNA (T) and two unidentified CNAs. Hand hygiene had been completed by CNAs H, K, L, and M, and by registered nurse (RN) (L) and (F). Cook Y had completed hand hygiene at appropriate times while preparing food during one of two meal preparation observations. Findings include: 1. Observation on 5/21/19 at 9:28 a.m. of COTA W while he worked with two random residents revealed: He used clothes pin clips with the first resident. With the second resident he used cones and a ball and stick. The ball and stick and clips were put directly in the supply cupboard after use without cleaning or sanitizing. Observation and interview on 5/23/19 at 9:33 AM with the COTA W while he worked with resident 125 revealed: He used pegs and a peg board with the resident. -He put the equipment directly back into the supply cupboard without cleaning or sanitizing them. Stated he usually wiped off the equipment after use but forgot to sometimes. *Agreed the equipment should have been cleaned after use with each individual resident. Interview on 5/23/19 at 10:07 AM with the director of physical therapy revealed he expected the resident use equipment to have been sanitized after use and before putting it away. Interview on 5/23/19 at 3:07 p.m. with the director of nurses r…	2020-09-01
108	108	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	550	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, call light audit review, and admission packet review, the provider failed to ensure dignity was maintained for one of one sampled resident (44) who had an incontinence issue. Findings include: 1. Observation and interview on 2/25/20 at 8:41 a.m. and again on 2/26/20 at 2:07 p.m. with resident 44 revealed: She had been resting in her recliner with her feet up with the call light next to her on her bedside table. Call lights had been answered slowly at times. She waited anywhere from thirty minutes to an hour for staff assistance. Due to her [DIAGNOSES REDACTED]. She had not usually been incontinent of urine but was concerned about the BM accidents she had. She chose to eat evening meals in her room at times to avoid BM accidents and long waits for assistance from staff to return to her room after she ate in the dining area. -It was difficult for her to sit for long periods of time due to back problems, and she also felt more tired in the evenings. She could get to the restroom independently using her walker. There was episodes when she could not make it in time and had BM all over that needed to be cleaned up. -When she pressed her call light for assistance, the wait after a BM accident was long. She thought the facility was short staffed at times which caused slow call light response times. -Staff had apologized to her for the long waits. She thought her last BM accident had been ten to twelve days ago. BM accidents usually happened about twice a month. That had happened mostly in the morning and sometimes in the afternoon. She stated she hated it, and it embarrassed her. Review of resident 44's medical record revealed: She was admitted to the facility on [DATE]. Her 12/24/19 Brief Interview for Mental Status (BI[CONDITION]) score was fifteen indicating she had no cognitive deficit. She had multiple [DIAGNOSES REDACTED]. She had frequently been incontinent of bowel. *She walked i…	2020-09-01
109	109	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	657	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor Based on observation, interview, record review, and policy review, the provider failed to review and revise care plans to reflect current needs of two of twenty-four sampled residents ([AGE] and 123). Findings include: 1. Review of resident 123's medical record revealed: She had been admitted on [DATE]. She had two pressure ulcers on admission. She had a history of [REDACTED]. She had a previous admission on 6/6/19 with pressure injuries and had been discharged on [DATE] without pressure injuries. She had a history of [REDACTED]. She also had two facility acquired pressure ulcers that had developed on 9/6/19 and 1/20/20. Review of resident 123's short term care plan with a date of 8/20/19 through 2/24/20 revealed: Several documented skin alterations, including the two facility acquired pressure ulcers. One notation of refusal of the pressure reducing device on her bed. There had been no interventions regarding positioning or incontinence care. Review of resident 123's care plan [DATE] for skin integrity revealed: Goal: Intact skin, but the focus was not clearly defined. Goal for: intact skin, free of redness, blisters or discoloration by/through review date 5/4/20. -It also indicated she was at risk for unavoidable altered skin integrity due to several factors. No revisions for interventions after she acquired two pressure ulcers while in the facility. The only intervention that was specific to the resident referred to the medication administration record (MAR) and treatment administration record (TAR); initiation date [DATE]. The care plan did not reveal she had pressure ulcers that had occurred while she was in the facility. *Focus: (name) has bladder incontinence r/t (related to) needing staff assist with her toileting tasks. -Goal was: Remain free from skin breakdown due to incontinence and brief use. -Interventions were: --Check as required for incontinence. --Monitor/document/report PRN (as necessary) any possible…	2020-09-01
110	110	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	658	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, manufacturer's recommendations review, and policy review, the provider failed to ensure a high risk medication was administered according to the manufacturer's instructions for one of one randomly observed resident's (50) [MED] given by one of one registered nurse (RN) (H). Findings include: 1. Observation, record review, and interview on 2/25/20 at 4:49 p.m. of resident 50's [MED] administration by RN H revealed: The resident received [MEDICATION NAME] 70/30 [MED] 25 units scheduled and [MEDICATION NAME] R [MED] 4 units according to her sliding scale dosing. The [MEDICATION NAME] 70/30 was in a vial and was a cloudy colored [MED]. The [MEDICATION NAME] R was in a separate vial and was clear colored. RN H drew up the 25 unit dose from the [MEDICATION NAME] 70/30 vial first, and then drew up the 4 units of [MEDICATION NAME] R into that same syringe. She then administered the above [MED] injection into the resident's upper left abdomen. RN H indicated the above process was her usual practice to draw up and administer the [MED] when the resident required the sliding scale [MED] along with her scheduled dose. Interview and record review on 2/26/20 at 9:08 a.m. with licensed practical nurse I regarding resident 50's [MED] administration revealed:She had worked there for several years and usually worked on resident 50's unit. She had given the resident's [MED] many times in the past. When discussing her process for the resident's [MED] administration she indicated she would have: -Put both the [MEDICATION NAME] 70/30 and the [MEDICATION NAME] R into the same syringe. -Drawn up the [MEDICATION NAME] R first and then the 70/30. She thought the clear [MED] should have been drawn up first and not the cloudy. She felt it was okay to put both those [MED]s into the same syringe until questioned by the surveyor. When asked how she could verify giving the two [MED]s together she got a copy of the p…	2020-09-01
111	111	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	686	E	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to appropriately implement, monitor, and alter care for three of six sampled residents (21, 118, and 123) who had multiple co-morbidities and were at risk for pressure ulcer/pressure injury development. Findings include: 1. Review of the provider's July 2017 Care Plan, Resident-Centered Facility Standards revealed: Care plans are written by exception and includes measurable outcomes and identify interventions that are specific to the individual resident with defined time frames or parameters. Pressure ulcer risk history section of policy revealed: -All residents admitted to (provider name) are considered at risk of developing pressure ulcers. -All residents have pressure relieving or reducing mattresses on their beds as well as pressure relieving or reducing cushions on their chairs unless otherwise specified on the individualized care plans. -All residents admitted to (provider name) are offered to be repositioned at least every two-three hours unless otherwise specified on the individualized care plan. Review of the provider's June 2018 policy for Pressure Sores Prediction and Prevention revealed: Policy: It is the responsibility of the Nursing staff at (provider name) to identify residents at risk, initiate preventive measures, and exercise early identification and treatment when noted. The four most critical factors that place our residents at risk are: -Pressure over a bony prominence. -Shearing-occurs when layers of tissue slide over each other. -Friction-occurs when two surfaces move against each other (as when a resident is slid in bed). -Moisture-leads to breakdown of the skin which enhances the risk of ulceration. This can be from urine, feces, perspiration or exudates (drainage). *To identify specific residents at risk, an initial assessment will be done with each admission referral and interventions put in place as indicated. Review of the p…	2020-09-01
112	112	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	692	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure: The nutritional status was monitored for one of three sampled residents ([AGE]) who had a significant weight loss and was nutritionally at risk. Nutritional intakes had been monitored for one of three sampled residents ([AGE]) who had a medication change to help increase her appetite. Findings include: 1. Observation and interview on 2/24/20 at 5:06 p.m. with resident [AGE] revealed she had: Been laying in her bed resting. Appeared very thin and frail with her bones easily visualized through her skin. Required the use of oxygen and became short-of-breath when talking to the surveyor. Been alert and able to voice her concerns without difficulty. Spent the majority of her days in her room. Stated: -Why would I want to go out there? -Who are you and just what do you want anyway? -You must be in on it. -And meals? No, I eat in my room. Review of resident [AGE]'s medical record revealed: An admission date of [DATE]. Her [DIAGNOSES REDACTED]. She required staff support of one person for all activities of daily living (ADL). -That had included bed mobility, transfers, walking, dressing, and personal hygiene. She: -Frequently refused assistance from the staff with those ADLs. -Was able to eat independently after the staff had set it up for her. -Was dependent on the staff to develop and implement a plan of care for her. -Was seen by telehealth and another counseling institute to monitor the stability of her mental health. -Chose to spend a majority of her time in her room. Her level of confusion fluctuated from day-to-day. She had: -A history of making unsafe choices for herself that had impacted her weight and nutritional health. -Frequently refused to have her weight monitored to ensure any concerns had been appropriately monitored and treated in a timely manner. -History of non-compliance with taking her medication. Review of resident [A…	2020-09-01
113	113	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	838	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the provider failed to ensure the facility assessment had addressed the staffing resources needed to ensure appropriate care and services were available to the residents. Findings include: 1. Review of the provider's 8/20/19 facility assessment revealed: Their resources for staffing needs had not been addressed. The assessment was eighteen pages long, and it included: -An overview indicating it was a 162-bed skilled nursing facility licensed by the State of [STATE] and certified by both the Medicare and Medicaid programs. -Services offered were: skilled nursing care and professional physical, occupational, and speech therapy services for both inpatient and outpatients. -The resident capacity was 162 with the current number of residents at 148. --The overall acuity of residents was left blank. -A listing of the total number of employee positions for administration and staff. --It had not specified how many staff were needed to care for the residents or how they would have been scheduled/assigned. -A listing of totals for resident diagnoses. --It had not specified how those [DIAGNOSES REDACTED]. -Eight of the sixteen pages listed physical environment and equipment within the building. -A listing of services provided by contract with a plan for annual reviews of them. -A listing of competency-based training for staff. -A page of health information managing and sharing. -A page for facility-based and community based risk assessment annual reviews. *There had been no mention of: -The facilities multi-level, multi-unit layout that included seven distinct nursing units. --Three of those seven were memory care units. -The third floor having more residents overall with higher level of care needs. -The usual amount of assistance required by the residents based on their medical and mental health diagnoses. -How the facility would have been staffed to ensure the residents' care needs were being met. Interview and f…	2020-09-01
114	114	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	867	D	0	1	Q3ZW11	Based on interview and policy review, the provider failed to implement an effective quality assurance process improvement (QAPI) program that focused on improving systemic problems. Findings include: 1. Interview on 2/26/20 at 1:35 p.m. with QAPI director K revealed: The committee met every month, and there were fifteen committee members. They reviewed the indicators on the Certification and Survey Provider Enhanced Reporting system (CASPER) report that were over the [AGE]th percentile. There could be other items that were under that percentile discussed, but the main focus was the CASPER report. They had a process improvement plan (PIP) they were working on for decreasing antipsychotic medication (med) use to meet the goal of 15 percent reduction of that med. Pressure ulcers and falls were on the agenda every month with updates given by director of nursing (DON) A. -They did not have a PIP for those items. Several times during this interview when asked for clarification on falls and pressure ulcers she said she knew we were going to ask for data, but she did not have it in her QAPI notes. Interview on 2/27/20 at 9:26 a.m. with administrator B and assistant administrator N revealed there was a large group of individuals that attended the meetings each month. Also agreed the QAPI meetings had become more of a reporting system and not an improvement program. Interview on 2/27/20 at 10:13 a.m. with DON A revealed she: Reported information on pressure ulcers and falls at the monthly QAPI meetings. Did not use a benchmark to determine the effectiveness of interventions or improvements. -Looked more at the individual than the system or overall trends. Did not have a system in place to effectively monitor trends. Focused on the resident versus systemic problems. Was unable to indicate how many pressure ulcers were facility acquired. Interview on 2/27/20 at 12:04 p.m. with medical director S regarding the QAPI meetings that he attended revealed he: Attended the meetings every month. *When he asked for further…	2020-09-01
115	115	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2020-02-27	880	D	0	1	Q3ZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions were maintained during personal care for 2 of 11 sampled residents (132 and 142) by one of one certified nursing assistant (CNA) (AA). Findings include: 1. Observation on 2/25/20 at 8:31 a.m. of CNA AA with resident 132 revealed: The resident had been in the bathroom waiting for assistance. He had required the use of a mechanical stand-aide for transfers and was already hooked-up to it. The CNA sanitized her hands and put on a clean pair of gloves prior to assisting the resident with personal care and a transfer. With those gloves on she: -Took a garbage bag off of a roll that had been on top of the glove box container. -Opened a dresser drawer and took out an incontinent brief and a bottle of perineal wash. -Touched the water faucet handle without using a barrier and turned on the water to wet a washcloth. -Assisted him with the mechanical stand-aide and raised it up to transfer him off of the toilet and provide personal care. With those now soiled gloves still on she took the washcloth, sprayed it with perineal cleanser, and provided perineal care for him. -She removed her gloves, put a clean incontinent brief on the resident, pulled up his pants, and transferred him to a recliner. Then washed her hands and left the room. 2. Observation on 2/25/20 at 1:03 p.m. of CNA AA with resident 142 revealed: The resident had been: -In her room sitting in a recliner. -Waiting for the CNA to assist her with a transfer, toileting, and personal care. She had required the use of a gait belt and a one person assistance for stand-pivot for transfers. The CNA sanitized her hands and put on a clean pair of gloves prior to assisting the resident with a transfer and personal care. With those gloves on she: -Put a gait belt around the resident's waist and transferred her to a wheelchair (w/c). -Opened the bathroom door and pushed the resident into the b…	2020-09-01
116	116	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2017-10-04	159	D	0	1	557P11	Based on interview, record review, and policy and review, the provider failed to ensure all residents' funds were in an interest bearing account for one of one resident trust fund account. Findings include: 1. Interview and record review on 10/4/17 from 10:00 a.m. through 10:45 a.m. with the staff accountant and assistant administrator regarding residents' trust funds revealed: There was one account containing residents' trust funds. The balance of the resident trust account was $8,935.97. The staff accountant reported the trust account had received no interest on that account since (MONTH) (YEAR). Both agreed the residents' trust funds were not in an interest bearing account. The assistant administrator agreed those funds needed to have been in an interest bearing account. Review of the provider's 10/4/17 Trust-Current Account Balance revealed: There were a total of forty-seven residents with a resident trust account. There were a total of thirty-two residents with a balance greater than $50.00. Review of the provider's (MONTH) (YEAR) Resident Trust Fund policy revealed: The provider offered each resident the opportunity to open a trust account. *All residents with monies in the residents' fund would have earned interest on the balance on the 17th day of each month.	2020-09-01
117	117	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2017-10-04	160	E	0	1	557P11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy and procedure review, the provider failed to return money belonging to five of five sampled deceased residents (25, 26, 27, 28, and 29) responsible party in the allotted time. Findings include: 1. Record review of the following deceased residents who had funds in the residents' trust funds account revealed: Resident 25 had died on [DATE] and $41.50 should have been returned to the resident's estate by [DATE]. If it had not been claimed the funds should have been sent to the state of South Dakota by [DATE]. - Nothing had been done with the funds. Resident 27 had died on [DATE] and $414.64 should have been returned to the resident's estate by [DATE]. If it had not been claimed the funds should have been sent to the state of South Dakota by [DATE]. -Nothing had been done with the funds. Resident 28 had died on [DATE] and $26.26 should have been returned to the resident's estate by [DATE]. If it had not been claimed the funds should have been sent to the state of South Dakota on [DATE]. -Nothing had been done with the funds. Resident 29 had died on [DATE] and $36.50 should have been returned to the resident's estate by [DATE]. -Nothing had been done with the funds. Resident 26 had died on [DATE] and $40.50 should have been returned to the resident's estate by [DATE]. -Nothing had been done with the funds. Interview and record review on [DATE] at 10:10 a.m. with the staff accountant regarding the above residents' trust funds revealed: She waited for the accounts received staff to let her know when to release the funds. She had not received permission for the above residents accounts to be released. She did not know there was an allotted time for those funds to be released. Interview on [DATE] at 10:30 a.m. with accounts received staff revealed: She was not aware of the accounts that had not been paid. She was not responsible for letting the staff accountant know when to release funds for ever…	2020-09-01
118	118	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2017-10-04	441	E	0	1	557P11	Based on observation, interview, record review, and policy review, the provider failed to ensure: Appropriate infection control was followed for one of one sampled resident (1) by one of of one observed licensed practical nurse (LPN) (B) during one of one dressing change. Proper handwashing and glove use was followed for two of six sampled residents (1 and 10) by two of six certified nursing assistants (CNA) (A and H) during personal care. Appropriate infection control was followed for one of one sampled resident (10) by one of one CNA (H) during one of one observed catheter care. Linens were covered for one of one observation during transporting and delivery by one of one observed hospitality aide (E). Findings include: 1. Observation on 10/4/17 at 10:00 a.m. in resident 1's room with LPN B revealed: She performed hand hygiene, put on a pair of gloves, and then: -Set a spray bottle of wound cleanser on the floor beside the resident. -Without laying down a protective barrier on the dresser she began to place a package of 4x4's and a package of Meplex dressing on it. -The Meplex dressing fell to the floor. -Removed the old dressing from the resident's left shin area. -Opened the package of 4x4s. -Picked the wound cleanser bottle up off the floor and sprayed the 4x4s with it. -Cleaned the area on and around the wound sight. -Removed her gloves and performed hand hygiene. -Put on a new pair of gloves. -Picked the Meplex dressing package up off the floor. -Opened the Meplex dressing package, removed the dressing, and applied it to the resident's left shin wound area. Interview on 10/4/17 at 9:00 a.m. with the director of nursing (DON) regarding the above revealed her expectations would have been for LPN B to have: Not placed wound supplies on the floor. Discarded the Meplex dressing package that had fallen on the floor and should have obtained a new dressing. Review of the provider's (MONTH) 2014 Dressing Changes Clean Technique policy revealed: Dressing change will be done by a licensed nurse using Clean Tec…	2020-09-01
119	119	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	604	D	0	1	L4X311	Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing assessments and care planning were completed for one of one cognitively impaired sampled resident (19) who was using a recliner with his feet up without access to the chair remote control. Findings include: 1. Random observations on 12/10/18 from 4:10 p.m. through 7:00 p.m., 12/11/18 from 7:00 a.m. through 6:30 p.m., and 12/12/18 at 7:15 a.m. thru 5:00 p.m. of resident 19 revealed: He was sitting in his recliner with his feet up except for meals. When asked how to put his feet down he replied he did not know what to do. His wife, who was his roommate, responded he could not have his remote, because he messed around with them and broke them. His chair remote was pinned to the back of his recliner on the 12/10/18 and 12/11/18 observations. Interview on 12/12/18 at 10:06 a.m. with the director of nursing (DON) regarding resident 19 revealed: His wife had requested him to not have the remote for his chair. She was not aware of any remotes that have been damaged. She agreed his wife's wishes should have been documented and care planned. His wife would put her light on when he needed help. Observation on 12/12/18 at 10:15 a.m. and at 2:05 p.m. in resident 19's room revealed: His feet were up while sitting in his recliner. His remote cord was tucked into the side chair cushion while the remote control hung down the front of his chair. -He could not see the remote control in that position. His remote had a handwritten note on it do not give to (name). His wife was sleeping in her recliner at both times above. Observation and interview on 12/12/18 at 2:07 p.m. with licensed practical nurse (LPN) N in resident 19's room revealed: A note had been taped on his chair remote by his wife. She was sleeping in her recliner. LPN N stated staff had taken off those notes, but she kept putting them back on. His wife had been asking staff to not give him the remote for the chair for approximately six months. *There …	2020-09-01
120	120	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	657	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure 3 of 29 sampled residents (19, 104, and 114) had their care plans updated and revised to reflect their current status and care needs. Findings include: 1. Observation and interview on 12/11/18 at 12:01 p.m. with resident 114's wife revealed: He was in his room sitting in a rocking wheelchair (w/c). -He had been sitting on a pressure relieving cushion. The mattress on his bed had: -An alternating pressure pad on it. High edges on both sides of it. His wife had been in his room visiting and spending time with him. His wife confirmed he: -had a history of [REDACTED]. -Was dependent upon the staff to ensure all of his activities of daily living (ADL) had been met. -Currently had a red area on his bottom. Review of resident 114's 8/23/18 Admission Referral/Baseline Care Plan information revealed: He had a left hip contusion from a fall and was at risk for falls. No documentation to support he: -Had required a special mattress to help him identify the edges for safety. -Had been at high risk for skin breakdown and required pressure relieving devices. -Was dependent upon the staff to ensure all of his ADLs had been met including repositioning. Review of resident 114's 9/12/18 comprehensive care plan revealed: No documentation to support he required: -A special mattress to ensure his safety from falls had occurred. -Repositioning to ensure skin breakdown had not occurred. Pressure relieving devices were put in place prior to skin breakdown occurring. Interview on 12/12/18 at 2:20 p.m. with Minimum Data Set (MDS) assessment coordinators [NAME] and K regarding resident 114 revealed they: Were responsible for the initiating, reviewing, and revising of all the care plans. -The charge nurses would have been expected to update the resident's short-term care plans. *Confirmed the direct caregivers would have used the comprehensive care plans to ensure …	2020-09-01
121	121	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	658	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to complete a comprehensive nursing assessment, document the assessment, and notify the physicians' of the findings of those assessments for two for two sampled residents (10 and 93). Findings include: 1. Review of resident 93's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Malignant neoplasm of bladder. -Retention of urine. -Other specified disorder of kidney and ureter. Review of resident 93's 11/6/18 Minimum Data Set (MDS) assessment revealed: He needed extensive physical assistance of one person in the following areas: -Personal Hygiene. -Toileting. He had an indwelling catheter. He had not had a significant weight loss or weight gain. Surveyor: Observation and interview on 12/11/18 at 4:33 p.m. with medication assistant P during resident 93's medication administration revealed:He had an indwelling catheter. The urine in his leg bag appeared to be a dark brownish-orange color. The medication assistant stated he had blood in his catheter recently. -Sometimes the resident would pull at the catheter. Staff documented the resident's urine output and the color of the urine on the report sheet for the next shift. -The nurse reviewed that report sheet every day. Surveyor: Review of the following Reflection's Unit reports for resident 93 indicated: 12/8/18 urine was dark amber during the day shift, and blood was present in his urine during the afternoon shift. 12/9/18 blood was noted in his urine on the night shift, and it was noted an amber color on the day shift. There was no urine appearance documentation of urine for the afternoon shift. 12/10/18 there was no urine appearance documentation. *12/11/18 Orange colored urine was documented on the night shift, dark red/brown color was documented on the day shift, and dark brown was documented on the afternoon shift. Interview with licensed practical nurse (LPN)/unit coordinator B on…	2020-09-01
122	122	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	686	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure three of eight sampled residents (29, 91, and 114) had the appropriate interventions in place and were repositioned to prevent pressure injuries from developing. Findings include: 1. Review of resident 29's medical record revealed: She had been admitted on [DATE]. Her [DIAGNOSES REDACTED]. She had a history of [REDACTED]. -Her current weight was one hundred and fifteen pounds. She had been dependent upon the staff: -To anticipate and assist her with all activities of daily living (ADL). -To develop and implement interventions for her to ensure pressure injuries had not occurred. Further review of resident 29's medical record revealed: She was alert with impaired cognitive capabilities due to her dementia. On 12/3/18 the staff identified a stage 2 pressure injury to her right inner buttock. -That pressure injury had been an intact fluid filled blister. On 12/5/18 a weekly wound assessment had been completed. -The staff had been directed to apply [MEDICATION NAME] barrier cream to that pressure injury. -A fax had been sent to the physician regarding the stage 2 pressure injury. -The son had been notified. No documentation to support: -The physician had responded or recommended a different type of treatment. -The wound had been healed as of 12/12/18. Review of resident 29's short-term care plan from 1/30/18 through 12/11/18 revealed: On 12/5/18 staff had documented: 0.7 x 0.4 cm (centimeters) clear, fluid filled blister (intact) to R (right) mid-inner buttock. -That documentation had occurred two days after the initial identification of the wound on 12/3/18. No further documentation to support: -What interventions were put in place for the staff to follow to promote healing of that wound. -If the physician and responsible party had been notified. -What specific treatment, if any, had been ordered to promote healing. -When or if the wound ha…	2020-09-01
123	123	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	692	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to ensure one of three sampled residents (93) received adequate hydration. Findings include: 1. Review of resident 93's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Muscle weakness. -Hypoxemia. -Malignant neoplasm of bladder. -Retention of urine. -Other specified disorder of kidney and ureter. -Unspecified [MEDICATION NAME] degeneration. -[MEDICAL CONDITION] without behavioral disturbances. Review of resident 93's 11/6/18 Minimum Data Set (MDS) assessment revealed: He had clear speech. His vision was highly impaired. He needed extensive physical assistance of one person for the following areas: -Bed mobility. -Transfer. -Walking in room. -Locomotion on unit. -Dressing. -Personal Hygiene. -Toileting. -Eating. He had an indwelling catheter. He had not had a significant weight loss or weight gain. Random observations from 12/10/18 through 12/12/18 at the following times of resident 93 revealed: 12/10/18 at 4:10 p.m. he was sitting in his recliner with music on and the water pitcher was across the room not, within his reach. 12/11/18 at 7:45 a.m. he was in his recliner with no music on and the water pitcher was across the room not, within his reach. 12/11/18 at 3:17 p.m. he was in the dining room for an activity with no fluids offered or within his reach. 12/12/18 at 8:29 a.m. he was sitting in the recliner and the water pitcher was not within his reach. -His lips appeared dried and chapped. -There was a loose piece of skin on his lower lip on the left side, near the corner of his mouth. 12/12/18 at 9:25 a.m. he was at an activity in the lounge and was offered a six ounce (oz) glass of juice. He drank it very quickly and was not offered more. 12/12/18 at 10:38 a.m. he was in his room sitting in his recliner with his eyes closed and the water pitcher was on the bedside table across the room. 12/12/18 at 12:32 p.m. licensed practi…	2020-09-01
124	124	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	697	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to implement an individualized and consistent process to assess, manage, and follow-up on pain for one of four sampled residents (114) who had high pain levels. Findings include: 1. Review of resident 114's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED]. His 8/23/18 Admission Referral/Baseline Care Plan information indicated: -He had weakness due to [MEDICAL CONDITION] with a left hip contusion from a fall. -He had pain in his back and left hip. --There was no documentation on what was used to help control his pain. On 8/23/18 the physician had ordered: -Tylenol extended release (ER) 650 milligram (mg) one tablet once a day for pain. -Tylenol ER 650 mg two tablets twice a day for pain. On 9/5/18 the physician had ordered Tylenol 325 mg two tablets every six hours as needed (PRN) for pain. He had been dependent upon the staff to assist him with all of his activities of daily living. His memory recall had been moderately impaired. Observation on 12/10/18 at 4:47 p.m. of resident 114 revealed: He had been in his room sitting in a rocking wheelchair (w/c). His wife had been there visiting with him. He had been visibly shaking. They had been waiting for the nurse to come in and assess him. Interview on 12/11/18 at 11:14 a.m. with resident 114's wife revealed: She confirmed he had arthritis in his back and that had caused him pain. *She stated: -I think they are trying to manage, it but I'm just not sure that they really are. -Last night he was shaking terribly, and no one knew why. -They stopped a med (medication) the doctor had recently started him on. -He's very sleepy today. Review of resident 114's 8/23/18 Admission Physical Nursing assessing revealed he had arthritic joint pain. At the time of the assessment he had not shown any signs of pain. Review of resident 114's 8/30/18 Admission Minimum Data Set (MDS) assessment indica…	2020-09-01
125	125	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	698	D	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, policy review, and outpatient services agreement review, the provider failed to follow professional standards for one of one sampled resident (112) who received [MEDICAL TREATMENT] treatments at an off-site facility including: Consistent assessments of the resident before and after [MEDICAL TREATMENT] treatments. Monitoring of the resident's [MEDICAL TREATMENT] shunt according to facility policy. Findings include: 1. Review of resident 112's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. He went to [MEDICAL TREATMENT] three times a week at an outpatient facility. Observation and interview on 12/10/18 at 4:29 p.m. with resident 112 revealed he: Went to [MEDICAL TREATMENT] three times a week at an outpatient facility. Had a pressure-type dressing in place to his left forearm shunt site. Stated he had [MEDICAL TREATMENT] earlier that day and would take the dressing off by himself later. Indicated the nurses did not do anything with his shunt site. Interview on 12/11/18 at 10:35 a.m. with licensed practical nurse (LPN) C regarding resident 112 revealed:He confirmed the resident went to [MEDICAL TREATMENT] every week on Monday, Wednesday, and Friday. He was independent and did most things himself. Review of resident 112's revised 11/29/18 care plan revealed:A focus area for .[MEDICAL TREATMENT] 3 times a week r/t (related to) [MEDICAL CONDITION]. -Interventions were: --Do not draw blood or take B/P (blood pressure) in Left arm with Shunt. --Encourage resident to go for the scheduled [MEDICAL TREATMENT] appointments. Resident receives [MEDICAL TREATMENT] 3 times a week.*A focus area of .at risk for shortness of breath, chest pains, [MEDICAL CONDITION], high blood pressure, infected access site, itchy skin, nausea, and vomiting d/t (due to) [MEDICAL TREATMENT] and abnormal blood sugar d/t diabetes.-Interventions included: --(Name) goes to Kidney [MEDICAL TREAT…	2020-09-01
126	126	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	842	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure complete and accurate documentation was in the medical record for 8 of 29 sampled residents (10, 19, 29, 91, 93, 104, 112, and 114). Findings include: 1a. Resident 114's medical record had incomplete documentation to support concerns of his need for better pain control. Refer to F697, finding 1. b. Resident 114's medical record had incomplete documentation regarding his pressure injury he had acquired while receiving care and services from the provider. Refer to F686, finding 2. 2. Resident 29's medical record had incomplete documentation regarding her pressure injury she had acquired while receiving care and services from the provider. Refer to F686, finding 1. 3. Resident 10's medical record had incomplete documentation of concerns for urinary tract infections, blood sugars, a fall, and chest pain. Refer to F658, finding 2. 4. Resident 104's medical record had incomplete documentation of concerns with her urination and the need for a catheter. Refer to F657, finding 2. 5. Resident 112's medical record had incomplete documentation to support assessments of his [MEDICAL TREATMENT] shunt and condition. Refer to F698, finding 1. 6. Resident 91's medical record had incomplete and inaccurate documentation regarding her pressure injury. Refer to F686, finding 3. 7. Review of resident 93's medical record revleaed there was no nursing documentaiton regarding fluid intake for him. The dietary department had only documented fluid intake one time per week. Refer to F692, finding 1. Interview on 12/12/18 at 3:05 p.m. with director of nursing revealed there was no policy for documentation. 8. Review of resident 19's medical record revealed there was no nursing documentation or care planning regarding his wife requesting to put his feet up and she did not want him to have access to his recliner remote control. Refer to F604, finding 1. Surveyor: 9. Interview on 12/12/18 at…	2020-09-01
127	127	JENKIN'S LIVING CENTER	435036	215 SOUTH MAPLE STREET	WATERTOWN	SD	57201	2018-12-12	880	E	0	1	L4X311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure: Two of two dietary aides (R and S) washed their hands and used gloves appropriately during two of two (supper and breakfast) meals observed in the third floor assisted dining room. One of one licensed practical nurse (LPN) (F) used proper technique during a dressing change for one of one sampled resident (139). One of one certified nursing assistant (CNA) (U) washed her hands and used gloves appropriately during catheter care for one of one sampled resident (73). Two of two CNAs (W and X) washed their hands and used gloves appropriately during personal care for two of two sampled residents (60 and 103). One of one LPN (Q) used proper handwashing techniques during medication administration for three of three randomly observed residents (3, 48, and 74). Findings include: 1. Observation on 12/10/18 from 5:30 p.m. to 5:50 p.m. revealed dietary aide (DA) R had brought the steam table to the third floor assisted dining room. During the observation time she: Had gloves on. Did not change them or perform hand hygiene while she poured drinks for the residents. Touched approximately half of the glasses with rims with her gloved hands. Also touched other surfaces including the countertop, wheelchair handles, and resident's skin, and clothing. Interview on 12/10/18 at 5:50 p.m. with DA R revealed she: Would have changed her gloves and washed her hands after she had brought the steam table to the dining room and before she started serving drinks. Agreed she had not changed her gloves or washed her hands during her time in the dining room. 2. Observation on 12/11/18 from 8:03 a.m. through 8:10 a.m. in the third floor assisted dining room revealed DA S: Served breakfast from the steam table. Had a glove on her left hand and no glove on her right hand. Used her gloved left hand to place bread in the toaster, remove the toasted bread, buttered the bread, cut the t…	2020-09-01
128	128	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2018-05-23	700	E	0	1	XUO711	Based on observation, interview, record review, and manufacturer's review, the provider failed to assess side rails for safety for ten of ten (1, 8, 9, 10, 14, 19, 27, 37, 38, and 41) residents who were randomly observed with side rails on their beds. Findings include: 1. Random observation on 5/21/18 from 12:30 p.m. through 5:45 p.m., on 5/22/18 from 7:00 a.m. through 5:45 p.m., and on 5/23/18 from 7:00 a.m. through 5:30 p.m. of residents 1, 8, 9, 10, 14, 19, 27, 37, 38, and 41 rooms revealed side rails were in the up position on each of their beds. Interview and record review on 5/23/18 at 8:00 a.m. with clinical care coordinator/licensed practical nurse [NAME] regarding side rails revealed: The side rail assessments were done quarterly. -They used to be in paper format, but now were in the electronic medical record. --Both forms had the same questions. The assessments had not clearly identified what safety aspects were reviewed. Review of the regulations related to side rails with him confirmed the assessments had not addressed whether: -Appropriate alternative interventions had been attempted prior to their use. -Appropriate installation and maintenance had occurred. -The risk of entrapment had been evaluated. -The risks and benefits had been reviewed with the resident or their representative. -Consent for use had been done prior to installation. -Manufacturers' instructions had been followed for the type of side rails being used. He confirmed side rails should have been evaluated for their safe use. Interview on 5/23/18 at 9:15 a.m. with clinical care coordinator/LPN [NAME] and clinical care coordinator/registered nurse (RN) F regarding side rail assessments revealed: They completed the side rail assessments quarterly. -Most residents used them for positioning and mobility. They had not discussed taking side rails off the beds of those residents who were not using them appropriately. They had not documented the safety aspects and risk of entrapment in the residents' medical records. RN F was unsure w…	2020-09-01
129	129	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2018-05-23	758	D	0	1	XUO711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (38) had documentation to support [MEDICAL CONDITION] medications had been administered appropriately. Findings include: 1. Observation on 5/22/18 of resident 38 revealed: At 7:37 a.m. he was sleeping in his bed. At 8:38 a.m. he was sleeping in his bed. At 10:18 a.m. he was sitting in his wheelchair in his room. Review of resident 38's medical record revealed: He was admitted on [DATE]. He had [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behaviors. -Muscle weakness. -Unsteadiness when on his feet. -Anxiety. -Dementia with behaviors. -Altered mental status. Review of resident 38's 12/19/17 psychiatric examination revealed: He Continues to have behavioral issues with resisting cares at times and agitation. He is given the prn (as needed) [MEDICATION NAME] and the prn [MEDICATION NAME] most days at least one time and sometimes more. He will continue on these medications and staff should monitor his medication use and behavioral response. Review of resident 38's (MONTH) (YEAR) consultant pharmacist's medication regimen review (MRR) revealed: I was reviewing his (MONTH) (YEAR) eMar (electronic medication administration record) to follow the use of [MEDICATION NAME] and [MEDICATION NAME]. -The use of these 2 agents appear to coincide with no time between doses to allow for 1 agent or the other to work. -This results in not knowing what, if anything is working. -We should use 1 agent at a time and document the results. Hand written note in Follow through area of document stated Education provided to staff. (name) LPN (licensed practical nurse) 4/10/2018. Review of resident 38's (MONTH) (YEAR) consultant pharmacist's progress note revealed: *[MEDICATION NAME] use for (MONTH) (YEAR) was eighteen tablets, and [MEDICATION NAME] use was thirteen tablets. -[MEDICATION NAME] use for (MONTH) (YEAR) was fifteen tablets,…	2020-09-01
130	130	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	253	D	0	1	POHR11	Based on observation, testing, interview, and record review, the provider failed to maintain the following items in a sanitary and/or safe condition: One of two beauty shop styling chairs was in need of a deep cleaning. One of one housekeeping central supply area had chemicals and cleaners stored so as to create possible contamination to hygienic paper goods. Findings include: 1. Observation on 5/23/17 at 9:00 a.m. revealed a yellow vinyl stylist chair in the beauty shop. That vinyl chair had a build-up of dirt and grime in the grooves that made the yellow color appear brown. Testing by running a fingernail across the chair left a clean trail of the color yellow beneath the removed grime. Interview with the beautician at the time of the observation and testing confirmed that finding. She stated she was a substitute that day for the regular beautician, but the chair appeared to need a deep cleaning. Interview on 5/23/17 at 9:00 a.m. with director of environmental services confirmed: The chair was dirty and appeared brown when the color of the chair was yellow. Housekeeping was responsible to clean beauty shop furniture and the floor at the end of each day. Review of the weekly room deep cleaning schedule revealed the beauty shop was not listed on any day of the week nor the week-ends. 2. Observation on 5/23/17 at 4:25 p.m. of the housekeeping central supply area revealed wire mesh shelves. Those shelves held large rolls of paper towels used to fill paper towel dispensers in handwashing locations. Those large rolls of paper towels were stored in direct contact and next to stainless steel polish, Clorox urine remover, Clorox bleach germicidal, and Kleenex foam skin cleanser. Interview on 5/23/17 at 4:25 p.m. with director of environmental services confirmed: Paper products and chemicals should not have been stored together on the same shelf. Chemicals should not be have been stored above paper products. *The large paper towels could be contaminated from the chemicals 3. Continued interview on 5/24/17 at 3:00 p…	2020-09-01
131	131	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	309	E	0	1	POHR11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy review, and contract review, the provider failed to ensure communication and documentation for hospice services had been incorporated into the medical records for two of three sampled hospice services residents (4 and 5). Findings include: 1. Review of resident 5's medical record revealed: He had been admitted on [DATE]. A hospice referral had been physician ordered on [DATE]. He had been admitted to hospice services on 3/29/17. The provider's plan of care (P[NAME]) dated 3/31/17 had been revised and had added I am on hospice. Please see hospice care plan for additional options. -That P[NAME] was located in his record at the nursing station. No hospice care plan had been identified in his medical record. Interview on 5/24/17 at 7:40 a.m. with the social services coordinator revealed she: Expected a hospice care plan to be located in the resident's paper chart at the nursing station. Confirmed the provider's current P[NAME] stated: -The resident was on hospice care. -See the hospice care plan for additional information. Interview on 5/24/17 at 9:35 a.m. with registered nurse (RN) A regarding care for residents who received hospice services revealed she: Would have looked at the hospice tab in the resident's paper chart to know how to care for the resident. Was not able to locate a hospice tab in resident 5's paper chart. Was not sure what services hospice provided or how often they visited the resident. Interview on 5/24/17 at 7:45 a.m. and at 2:50 p.m. with the director of nursing services regarding resident 5's care plan revealed: The hospice care plan was not in the facility as of 5/23/17 when it had been requested by the surveyor. The process would have been to have a Hospise care plan in the medical record. She would have expected to have found it in the paper chart at the nurses station. They would refer to the hospice care plan when information was needed on hospice services. *She …	2020-09-01
132	132	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	323	D	0	1	POHR11	Based on observation, testing, and interview, the provider failed to ensure housekeeping cleaners and disinfection chemicals were not accessible to residents in the following areas: One of two therapy rooms (restorative). One of one shared bathroom between two of two therapy program rooms. Findings include: 1. Observation on 5/23/17 at 3:40 p.m. of the restorative therapy (RT) room revealed: The corridor door to the room was wide open. No one was in the room, but residents were noted in the corridor. A tall wooden cabinet had a key in the door. -Testing of that door revealed it had been left ajar. -A shelf in that cabinet had a container of Sani-Cloth Plus disinfectant wipes. Continued observation of the shared bathroom between the RT program room and the physical/occupational therapy (PT/OT) room revealed: The corridor door to the PT/OT room was wide open. No one was in the room, but residents were noted in the corridor. Both bathroom doors were opened between the two rooms. -All residents had access to that bathroom. Two containers sat next to each other on the tank of the bathroom toilet. Those containers were: -A flat package of resident personal care wipes commonly used for personal hygiene. -A round container of Sani-Cloth Plus disinfectant wipes. --Review of that Sani-Cloth Plus label revealed: ---They were germicidal disposable cloths. --Precautionary statement read: ---Hazards to human and domestic animals. ---Not for use on skin. Interview on 5/23/17 at 3:40 p.m. with the director of environmental services confirmed: The disinfection wipes were used on equipment in the therapy programs. Sani-Cloth Plus wipes should not have been stored accessible to residents. The wooden cabinet in the RT room should have been locked, and the key removed from the door. The Sani-Cloth wipes in the bathroom should have been stored in a locked cabinet. Interview on 5/24/17 at 9:25 a.m. with the occupational therapist revealed she: Was not aware the Sani-Cloth disinfectant wipes should not have been stored in …	2020-09-01
133	133	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	431	F	0	1	POHR11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the provider failed to ensure medical supplies were not outdated in: One of one therapy room for one two gallon container of ultrasonic gel that had expired (MONTH) (YEAR). One of one central nurses supply area for: -Five of five sodium chloride 500 milliliter (ml) irrigation solution expired (MONTH) (YEAR). -Three of three bottles of 70% isopropyl alcohol 16 ounces (oz) expired (MONTH) 2014. -Five of five hydrogen peroxide 16 oz expired (MONTH) (YEAR). Two of two treatment carts: -Two boxes filled with 3 ml sodium chloride (NaCl) expired plastic vials. --Those expiration dates ranged from (MONTH) 2014 through (MONTH) (YEAR). -Two 16 oz bottles of hydrogen peroxide expired (MONTH) (YEAR). One of one medication room for three of three intravenous (IV) solutions that had expired (MONTH) (YEAR). Findings include: 1. Observation on [DATE] at 3:45 p.m. of one of two therapy rooms revealed an in-use, approximately two gallon plastic flexible container of Ultrasonic Gel that had expired (MONTH) (YEAR). That container had been opened and approximately an eighth of the gel was left. Interview at the time of the above observation with the director of environmental services confirmed: Expired items should have been discarded. Therapists were responsible for checking expiration dates on their supplies. Interview on [DATE] at 9:25 a.m. with the occupational therapist revealed: They used that large container of gel to fill the small squirt bottles throughout therapy. They had not checked the expiration date before they filled the small squirt bottles. She was not aware the ultrasonic gel had an expiration date. 2. Observation on [DATE] at 4:25 p.m. of the nursing central supply area revealed the following: Five sodium chloride irrigation 500 ml bottles had expired (MONTH) (YEAR). Three 16 oz bottles of 70% isopropyl alcohol had expired (MONTH) 2014. Five 16 oz bottles of hydrogen peroxide had expired (MONTH) …	2020-09-01
134	134	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2017-05-24	441	F	0	1	POHR11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, testing, label review, document review, and interview, the provider failed to ensure: One of one sampled resident (1) on isolation precautions was treated in a manner to control and prevent the spread of the disease to other residents, staff, and visitors. Two of two bath aides (J and K) followed manufacturer's directions for disinfection of two of two whirlpools. Dishware, utensils, cookware, and extra kitchen items were protected from possible contamination from an overhead sewer line in one of one basement kitchen storage room. One of one [MEDICATION NAME] wax hand therapy basin was cleaned in accordance to the manufacturer's directions. Medical supplies, resident hygienic use items, wound care supplies, and medication pass supplies were stored protected from possible contamination in one of one basement nursing supply storage room. Clean linens from three of three washers were protected from possible contamination by one of one dirty wall mounted oscillating fan. Findings include: 1.a. Observation on 5/23/17 at 7:10 a.m. of resident 1's doorway revealed: The door to her room was shut. On top of a plastic cart in the alcove by her room was: -A box of gloves. -A laminated sign with gloves, gown, and a mask written on top of it. -Next to the word glove was a check mark. Inside the three drawers of the cart were red garbage bags, disposable gowns, masks, and gloves. There was no signage in the immediate area indicating visitors, staff, and residents should visit with the nurse prior to entering that room. Interview at the time of the above observation with registered nurse (RN) F revealed: The resident had: -Been placed on isolation precautions on 5/20/17 for a [DIAGNOSES REDACTED]. -Required contact isolation precautions. She confirmed there was no sign in the immediate area indicating visitors, staff, and residents should have checked with nursing prior to entering her room. But we do have signs. *She state…	2020-09-01
135	135	CLARKSON HEALTH CARE	435037	1015 MT VIEW RD	RAPID CITY	SD	57702	2019-08-14	657	D	0	1	BSIS11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure 1 of 13 sampled residents' (24) care plans were updated and revised to reflect the resident's current status and care needs. Findings include: 1. Random observations on 8/12/19 between 1:03 p.m. and 5:30 p.m. of resident 24 revealed: She had required assistance from one staff person to transfer her from wheelchair to bed. -She had been in bed most of that afternoon. Staff had pushed her in the wheelchair to the dining room for dinner at 5:05 p.m. -She had required verbal and physical assistance from staff to eat. -She had hung her head and kept her eyes closed for most of the meal. -Her intake was poor. Random observations on 8/13/19 from 7:30 a.m. until 10:58 a.m. of resident 24 revealed: She was asleep in bed between 7:30 a.m. and 9:35 a.m. She had been pushed in her wheelchair by staff to a common area at 10:58 a.m. to listen to staff read the news. -Her head was down, and her eyes were closed during that activity. Review of resident 24's medical record revealed: Her [DIAGNOSES REDACTED]. She had weighed 92 lb (pound) on 3/23/19 and had weighed 82.5 lb the week of 8/5/19. She had become physically weaker in the last few months. On 7/24/19 her physician had ordered all nutritional supplements be stopped and had continued only medications that had helped the resident remain comfortable. Review of resident 24's 6/22/19 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status score was three indicating severe cognitive impairment. Interview on 8/14/19 at 1:30 p.m. with clinical care coordinator A included review of resident 24's last updated 7/29/19 care plan and revealed: a. Activities of Daily Living Function: *I have a restorative program d/t (due to) decreased endurance and balance precautions, overall weakness and lack of motivation. Start date was 10/18/18. -That program had included mobility, standing, wheelch…	2020-09-01
136	136	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-01-31	689	E	1	0	NOYG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, and policy review, the provider failed to ensure: Timely preventative maintenance to include checking lift clips for one of three total mechanical lifts (2) to prevent a fall for one of one sampled resident (1). Staff education and training for all direct care staff including four of four interviewed certified nurse assistants (CNA) (A, B, C, and D) about proper usage, sling selection, and appropriate maintenance of total mechanical lifts when used with sampled residents 1, 4, and 5. Findings include: 1. Review of resident 1's 1/18/18 South Dakota Department of Health (SD DOH) event report revealed: Certified nursing assistants (CNA) D and F had been transferring the resident into her wheelchair with the total mechanical lift. The sling hooked on the right front hook slide off Hoyer hook when sling was pulled back to sit resident straight into her w/c (wheelchair). The resident fell forward and hit the right side of her head on the floor. The lock on the right hook did not go into lock position causing the right sling hook to slide off Hoyer. The equipment malfunction was written up for the maintenance department, and the Hoyer lift had been removed from the floor. The report had been completed by licensed practical nurse [NAME] Observation on 1/30/18 at 3:50 p.m. in the 100 hallway revealed on Hoyer lift 4 one of four clips was broken. Interview on 1/31/18 at 9:00 a.m. with CNA D regarding resident 1's fall out of the lift revealed: She had been employed at the facility for approximately sixteen years. They had been using the total mechanical lift labeled 2. All four clips had been broken on the lift prior to transferring resident 1 on 1/18/18. The clips had been broken for awhile, but she was not sure how long they had been broken. She had not reported the broken clips to maintenance. She had not had training on proper use and maintenance of the lifts since she had been employe…	2020-09-01
137	137	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-01-31	867	E	1	0	NOYG11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, and policy review, the provider failed to identify concerns with multiple falls and to implement an effective performance improvement plan (PIP) and quality assurance program. Findings include: 1. Review of the provider's event summary report from 11/1/17 through 1/30/18 revealed there had been thirty-two falls involving sixteen residents. Interview on 1/31/18 at 12:25 p.m. with the quality assurance program nurse revealed: She had been in the role for about two years. She had received some training from the state quality assurance coordinator at the beginning. She was also the infection control nurse, the grievance official, and worked on the floor two days a week. -Today she had been scheduled to work in the office and not on the floor. Relevant to falls, she had taken over completing post fall huddle reports because CNAs and other staff were not completing them. -They had not looked at the data collected to determine staffing issues or environmental issues. -Interventions were implemented after the fall had occurred. -The falls PIP had been going on since (MONTH) (YEAR). Other PIP projects she was currently working on included: -Pressure ulcers - no date of initiation. -[MEDICATION NAME] screening - no date of initiation. -Food temperature recording was initiated in (MONTH) (YEAR). --She was unsure why the dietary manager was not involved with this PIP. -Perineal and catheter care was initiated in (MONTH) (YEAR). -Self-administration of medications was initiated in (MONTH) (YEAR). She had been in charge of all the above PIPs. Interview on 1/31/18 at 1:00 p.m. with the director of nursing revealed they had not had other department heads involved in the quality assurance PIP process. Review of the provider's undated Quality Assurance Performance Improvement policy revealed goals were to incorporate quality process assessment, evaluation, and improvement planning for all systems sustaining of improve…	2020-09-01
138	138	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	225	D	0	1	V4R811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to investigate and report one of one sampled resident's (16) fall with the use of a full-body lift to the South Dakota Department of Health (SD DOH). Findings include: 1. Review of resident 16's medical record revealed: She was admitted on [DATE]. She had current [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] -[MEDICAL CONDITION]. -[MEDICAL CONDITION], one eye. Her 8/12/17 quarterly Minimum Data Set assessment showed a Brief Interview for Mental Status score of fifteen indicating she was cognitively intact. Review of resident 16's 8/2/17 fall report revealed she: Was being transferred with the full-body lift. Was over the bed when the sling slipped off the lift, and she hit her head on the wall. Had a small raised area to the back of the left side of her head. Interview on 8/24/17 at 9:45 a.m. with the social services director revealed: She was not aware the incident needed to be reported to SD DOH since the resident did not have a major injury and was not sent to the hospital. There was no investigation to determine if there was a mechanical issue with the lift or if the resident was transferred incorrectly. Interview on 8/24/17 at 10:30 a.m. with the administrator revealed she acknowledged the incident had not been investigated and reported the SD DOH. Review of the provider's undated Abuse policy revealed, The investigative process includes a thorough assessment of the resident involved, interviews and observations with the resident, interviews with the staff members and interviews with the person involved .	2020-09-01
139	139	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	279	D	0	1	V4R811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to develop a comprehensive care plan based on the individual residents' care areas for three of nine sampled residents (4, 6, and 7). Findings include: 1. Review of resident 7's 9/28/16 annual Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) revealed: Her Brief Interview for Mental Status (BIMS) score was nine indicating her cognition was moderately impaired. She had an unplanned weight loss. The following CAAs were triggered: -Cognition loss. -ADL function/rehabilitation (rehab) potential. -Urinary incontinence/catheter. -Falls. -Nutritional status. -Dental care. -Pressure ulcers. Review of resident 7's weight records revealed from 6/13/17 through 6/26/17 she had an eleven pound weight loss. Observation and interview on 8/22/17 at 2:00 p.m. with resident 7 revealed she was sitting in a wheelchair in her room. She had been drinking a pink drink and when asked what it was she stated They want me to drink it because of my weight. Review of resident 7's 7/12/17 care plan revealed nutritional status and pressure ulcers had not been addressed on the care plan. There were no interventions listed for the resident's weight loss. 2. Review of resident 6's 11/14/16 annual MDS assessment and CAAs revealed: Her BIMS score was nine indicating her cognition was moderately impaired. She used tobacco. The following CAAs were triggered: -[MEDICAL CONDITION]. -Cognition loss. -Communication. -ADL function/rehab potential. -Urinary Incontinence/catheter. -Mood state. -Falls. -Nutritional status. -Dental care. -Pressure ulcers. Observation and interview on 8/22/17 at 4:35 p.m. with resident 6 revealed: She had been outside in the smoking area smoking a cigarette. She was not wearing an apron. Two of her daughters resided in the facility. One of the daughters held her cigarettes and lighter for her. *That was her last cigarette, and her daughter was ou…	2020-09-01
140	140	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	315	E	0	1	V4R811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the provider failed to prevent the reoccurrence of urinary tract infections [MEDICAL CONDITION] for two of two sampled residents (8 and 9) with a catheter by ensuring: Personal care was provided as per care plan or as provider's policy. Drainage bags were kept in a position to promote urine flow by gravity. Findings include: 1. Review of resident 8's complete medical record revealed: She was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Her current care plan stated: -To check and change her brief every two hours and as needed. -To provide incontinence care after an incontinence episode. -Position foley catheter bag below the bladder. She was always incontinent of stool due to her MS and often had smears with peri-care. She leaked urine around her catheter tubing. Her certified nursing assistant (CNA) flow sheet did not mention catheter care. Observation on 8/22/17 at 12:45 p.m. with resident 8 revealed: CNA [NAME] emptied her foley catheter drainage bag and did not use an alcohol swab to clean the spout. Her foley catheter bag had been hanging on the footboard of the bed above her bladder. LPN G changed her adult brief, and she had a small bowel movement. No peri-care or catheter care was done. LPN G wiped her anal area. Observation on 8/23/17 at 9:20 a.m. with resident 8 revealed: LPN G had changed her coccyx dressing. The foley catheter bag had laid on the end of the bed, even with her bladder. Staff had left the room with the bag laying on the end of the bed between the resident's legs. Observation on 8/23/17 at 2:00 p.m. and at 3:30 p.m. with resident 8 revealed the foley catheter bag had been laid at the end of her bed between her legs. Observation and interview on 8/24/17 at 9:05 a.m. in resident 8's room with CNA F revealed she: Had emptied the urine out of the drainage bag. Had not used an alcohol swab to clean the end of the spout. *Stated the reside…	2020-09-01
141	141	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	323	D	0	1	V4R811	Based on observation, record review, and interview, the provider failed to appropriately assess one of one sampled resident (12) who attempted to exit the facility. Findings include: 1. Observation on 8/22/17 from 4:30 p.m. through 5:20 p.m. of the front door revealed: At 4:30 p.m. the alarm had been not sounding. Visitors had been walking in and out of the building through that door. The receptionist had been sitting at the desk looking down. At 4:50 p.m. resident 12 walked out the front door and stood on the sidewalk. -She turned and came back inside. At 5:01 p.m. resident 12 went to the front door again where two visitors redirected her to the chair. At 5:09 p.m. she went to the front door again. -Licensed practical nurse (LPN) L asked an unidentified CNA to redirect resident 12 from the front door. Resident 12 said she was waiting for someone and did not want to miss them. At 5:11 p.m. LPN L reset the door alarm system, and the alarm sounded again. Interview on 8/22/17 at 5:25 p.m. with LPN L regarding resident 12 revealed: The resident was confused. She thought she was waiting for someone, but there was no one coming for her. The resident would go outside by herself sometimes and sit on the bench. She did not have a Wanderguard on her. Review of resident 12's 6/8/17 Minimum Data Set assessment revealed she had a Brief Interview for Mental Status score of three indicating her cognition was severely impaired. She ambulated on her own with a walker. Review of resident 12's 6/8/17 Elopement Risk assessment revealed she was at low risk for leaving the facility. Interview on 8/23/17 at 1:45 p.m. with the maintenance supervisor regarding the front door revealed: There were two buttons to turn off the system. One button acknowledged the person walking in the door. -The alarm would be silenced until it was reset. -The lights behind the nursing station would stay on. *The second button would reset the alarm, so it sounded anytime a person walked in or out of the building. Interview on 8/24/17 at 9:00 a.m…	2020-09-01
142	142	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-08-24	371	D	0	1	V4R811	Based on observation, interview, and policy review, the provider failed to ensure the recording of food temperatures in one of two kitchen observations. Findings include: 1. Observation on 8/22/17 at 8:00 a.m. during the initial walk through tour of the kitchen revealed: A Food Temperature Monitor log in the kitchen. -Had been dated from 5/17/17 to 8/18/17. -Had several meals and dates missing. -Had no temperatures recorded after 8/18/17. Interview on 8/22/17 at 8:10 a.m. with cook A revealed he: Had checked the breakfast food temperatures. Had not recorded them on the log. Forgot to record food temperatures frequently. Interview on 8/22/17 at 12:30 p.m. with cook B revealed she: Had checked the lunch food temperatures. Forgot to record food temperatures frequently. Interview on 8/24/17 at 9:30 a.m. with the dietary manager revealed she: Had always checked food temperatures when she was cooking. Forgot to record food temperatures frequently. *Had the expectation that all food temperatures were to be checked and recorded at each meal. Interview on 8/24/17 at 12:45 p.m. with the administrator revealed she had the expectation that all food temperatures were to be checked and recorded at each meal. Review of the provider's undated Food Temperatures policy revealed Take temperatures often to monitor for safe food holding temperature ranges of at or below 41 degrees F for cold foods; and at or above 135 degrees F for hot foods.	2020-09-01
143	143	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	554	E	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure steps had been completed to support appropriate self-administration of medications for five of five residents (3, 20, 22, 26, and 40) who self-administered their medications. Findings include: 1. Observation on 10/31/18 at 10:40 a.m. of unlicensed assistive personnel (UAP) B during a nebulizer medication administration for resident 22 as she sat upright in her chair revealed the UAP: Poured the [MEDICATION NAME] inhalation medication into the chamber of the nebulizer. Called the resident's name until she opened her eyes. Attached the nebulizer mask around the resident's face. Turned on the machine. Said she would return to the resident's room in ten to fifteen minutes when the nebulizer medication was finished. UAP B was asked at this time if the resident was capable of keeping the medication mask on for the full treatment, and if she would know if the resident had received all of the medication. The UAP replied: Resident 22 slept most of the time. Sometimes she removed the mask and shut the machine off herself. When that happened she would reapply the mask and start the machine again. Residents were assessed for their ability to self-administer medications. -She did not know if there was documentation of their ability to self-administer those medications. The medication administration record (MAR) had not indicated if this resident was able to self-administer medications. At 11:10 a.m. UAP B reentered resident 22's room and stated: The resident had removed the mask herself while she was out of her room. There was still some medication left in the nebulizer chamber. She would wake the resident and reapply the mask until the medication was gone. She was not sure if the other UAPs or nurses had completed the nebulized medication when the resident had removed her mask. Review of resident 22's medical record revealed: *She was admitted o…	2020-09-01
144	144	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	637	D	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and Resident Assessment Instrument (RAI) manual review, the provider failed to complete a significant change of condition Minimum Data Set (MDS) assessment for one of one sampled resident (42) who required more physical assistance. Findings include: 1. Random observations on 10/30/18 from 8:00 a.m. through 5:30 p.m. and 10/31/18 from 8:00 a.m. through 4:00 p.m. of resident 42 revealed: She spent most of her time alone and on her bed. She had little interaction with staff or other residents. Interview on 10/30/18 at 2:30 p.m. with the MDS coordinator regarding resident 42 revealed: She had been feeling sick for the last few weeks. The physician had increased her anxiety medication on 10/2/18, because she was restless and had exhibited increased physical and verbal aggression. The physician discontinued the medication on 10/17/18 when physical changes were noted. She had continued to exhibit declines in her abilities. Review of resident 42's medical record revealed: She was admitted on [DATE]. [DIAGNOSES REDACTED]. On 10/2/18 her physician had increased her [MEDICATION NAME] due to increased restlessness and anxiety. On 10/10/18 she was found on the floor, and no injury was identified. After this event: Physical therapy was ordered, but the resident refused to be evaluated. Her [MEDICATION NAME] was discontinued on 10/17/18 due to increased sedation and confusion. [MEDICATION NAME] was ordered 10/17/18 after the nurse noted some respiratory concerns. Review of her quarterly 7/26/18 MDS assessment revealed: In section C her Brief Interview for Mental Status (BIMS) score was three indicating she had severe cognitive impairment. In section D, mood severity she: -Exhibited feeling tired two to six days a week. In section E, behaviors she: -Exhibited physical and verbal aggression one to three days a week. -Wandered one to three days a week. In section G, activities of daily living (ADL…	2020-09-01
145	145	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	686	D	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure one of three sampled residents (33) who had developed a pressure ulcer while in the facility had ongoing assessments, wound documentation, care planning, and appropriate dietary interventions. Findings include: 1. Observation and interview on 10/30/18 at 10:18 a.m. in resident 33's room with certified nursing assistants (CNA) C and D revealed they were going to transfer her with the mechanical lift from the wheel chair into the bed. Following the transfer they were going to check her for incontinence and do perineal (peri)-care. Before continuing with the transfer the surveyor had asked the residents permission to remain in the room to observe. She declined so the surveyor exited the room prior to the transfer. Observation and interview on 10/31/18 at 9:22 a.m. in resident 33's room with two CNAs revealed they were going to transfer her with the mechanical lift from the wheel chair into the bed. Following the transfer they were going to check her for incontinence and do peri-care. Before continuing with the transfer the surveyor had asked the residents permission to remain in the room to observe. She declined so the surveyor exited the room prior to the transfer. Review of resident 33's medical record revealed the following nursing progress notes: On 10/8/18 at 4:43 a.m.: During personal cares resident was noted to have 2 red areas to the top, middle area of her buttocks, large one measures 3 cm (centimeter) x 1.5 cm, the smaller one measures 1 cm x 1 cm. No open areas noted. On 10/8/18 at 3:17 p.m.: (Physician name) notified of 2 reddened areas to coccyx. Telephone order received to apply Bag Balm topically to buttocks with each brief change. On 10/23/18 at 3:34 p.m.: Assessed resident's buttocks today. There are no red areas and no open areas at this time. There was no documentation the certified dietary manager (CDM) or registered dietitian…	2020-09-01
146	146	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	698	D	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow professional standards for one of one sampled resident (1) who received [MEDICAL TREATMENT] at an off-site facility including: Assessment of resident before and after [MEDICAL TREATMENT] treatment. Ongoing communication between the [MEDICAL TREATMENT] facility and the provider. Findings include: 1. Observation on 10/31/18 at 8:17 a.m. revealed resident 1 had left for her scheduled [MEDICAL TREATMENT] treatment at an off-site [MEDICAL TREATMENT] facility. Review of resident 1's medical record revealed: She received [MEDICAL TREATMENT] at an off-site [MEDICAL TREATMENT] facility on Mondays, Wednesdays, and Fridays. No documentation was found regarding: -Her vital signs and health status before or after [MEDICAL TREATMENT] treatments. -If she had been monitored for [MEDICAL TREATMENT] related complications such as bleeding, [MEDICAL CONDITION], or excess fluid. -Communication between the [MEDICAL TREATMENT] facility and the provider before or after [MEDICAL TREATMENT] of her vital signs, weights, health status, or treatment provided. Review of the provider's 6/9/16 [MEDICAL TREATMENT] and Fistula Intervention Policy and Procedure revealed: On resident's arrival back to the facility (provider) from [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) facility, resident should arrive with [MEDICAL TREATMENT] Communication Form or the [MEDICAL CONDITION] facility should fax back to LTC (long term care) facility. Observation and interview on 10/31/18 at 1:02 p.m. with resident 1 regarding her [MEDICAL TREATMENT] routine revealed she: Had returned from her scheduled [MEDICAL TREATMENT] treatment. Had [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays. *Stated she did not take any papers with her to the [MEDICAL TREATMENT] facility and they did not send any papers back with her. Interview on 10/31/18 at 2:53 p.m. with the director of nursing (DON…	2020-09-01
147	147	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	761	E	0	1	1P5611	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to have a system in place to maintain the security of biohazards such as used syringes and narcotic [MEDICATION NAME]es in sharps containers that were ready for destruction in two of two unsecured soiled utility rooms (north and east) and one of one unsecured biohazard room. Findings include: Surveyor 1. Observation on 10/30/18 at 4:15 p.m. in the basement was an unlocked door with a sign on it marked Biohazard. The unlocked door led into a room that had two boxes on the floor. Inside of the boxes were items in red biohazard bags. Surveyor Observation on 10/31/18 at 2:00 p.m. with licensed practical nurse (LPN) A of the north medication (med) room and north med cart revealed sharps containers on the med room wall and med cart were attached to the wall or cart. Interview with LPN A at that time regarding the sharps containers revealed when the containers were full: The nurse: -Used a key to remove the sharps containers from the med cart or med room wall. -Closed the lid of the plastic container. -Brought the full container to the soiled utility room. -Placed the container in a cardboard biohazard box. When the biohazard box was full someone would remove the box from the soiled utility room and transferred it to the biohazard room in the basement. She was not sure who brought the biohazard box to the biohazard room. She confirmed: -The soiled utility rooms were not locked. -All staff had access to the sharps containers in the soiled utility rooms. When asked if nurses placed any medications into the sharps containers she stated: -Medications up for disposition were supposed to have been destroyed. -Medications should not have been placed in sharps containers. -She did not place used medication vials in sharps containers. When questioned what the provider's policy was for destroying [MEDICATION NAME] narcotic patches she stated: -She was not sure what the policy was. -…	2020-09-01
148	148	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2018-10-31	880	E	0	1	1P5611	Based on observation, interview, and policy review, the provider failed to ensure infection control practices were maintained for: One of one observed bed making, clean linen cart so it was not cross-contaminated with soiled linens. One of four dryer drum windows that had a cleanable surface Four of four randomly observed residents' rooms (215, 217, 218, and 221) that had rusted side rails. Hand hygiene between residents' rooms by one of one housekeeper (G). Findings include: 1. Observation and interview on 10/30/18 at 9:10 a.m. in the east hallway revealed: A linen cart with a large rip on the top right hand corner cover. On the left middle section of that cart was a plastic bag with soiled cloths in it. Interview at that time with housekeeper [NAME] regarding the cart revealed: She used the cart for changing bed linens. The cart contained clean sheets, blankets, and soaker pads. She used the cloths to clean the beds and wipe the walls and door frames. She discarded the soiled cloths into the plastic bag attached to the linen cart. Interview on 10/31/18 at 8:25 a.m. with the head of housekeeping regarding the above linen cart revealed the soiled cloths should not have been stored on the clean linen cart. Surveyor 2. Observation on 10/30/18 at 9:00 a.m. of the 200 wing and on 10/31/18 at 3:30 p.m. confirmed four private residents' rooms 215, 217, 218, and 221 contained beds with half side rails on each side at the head of the beds. All of those side rails had chipped paint and rusted areas. Interviews on 10/31/18 at 4:30 p.m. with the director of nursing (DON) and again at 5:10 p.m. with the administrator revealed: The DON was aware of the poor condition of the side rails. The administrator was not aware of the rusted areas on the side rails. Both the DON and the administrator confirmed the rusted areas were not washable surfaces and created an infection control hazard. The maintenance supervisor was not available for interview. Surveyor 3. Observation and interview on 10/30/18 at 10:26 a.m. in the …	2020-09-01
149	149	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	585	E	1	0	QFLH11	> Based on interview and policy review, the provider failed to have a facility based system in place to document grievances brought to their attention by staff, residents, or family members. Findings include: 1. Interview on 11/28/17 at 11:00 a.m. with an anonymous family member revealed she had been yelled at by a staff member a few weeks back. While she could not recall the name of the staff member who had yelled at her, she identified another staff member who had witnessed the event. Interview on 11/28/17 at 11:15 a.m. with an anonymous staff member revealed: Earlier in the month she had overhead certified nursing assistant (CNA) C getting loud with the above family member and resident. She had been walking down the hall towards the residents' rooms when the voices started to get loud. She had walked into the room and heard CNA C yelling at the family member. She had reported the incident to the charge nurse. She was unable to remember who the charge nurse was that night. Interview on 11/28/17 at 1:30 p.m. with the social services designee and the director of nursing (DON) regarding their grievance process revealed they: Had no way of tracking grievances. Were unable to provide what grievances had been received since 9/18/17, and how those grievances were resolved. Stated grievances were handled on an individual basis but could not provide what grievances they had looked into and resolved. Interview on 11/28/17 at 1:45 p.m. with the administrator revealed: They currently had a grievance form that staff should have been filling out but were not. They were changing the process but had no timeline for when that would be implemented. The DON had received a note under her door on 11/27/17 regarding CNA C and her behavior being inappropriate towards family and residents. -The note had not been signed. They were waiting to talk to CNA C on 11/29/17, as that was the next shift she was scheduled to work. They had not started an investigation into the matter. They had not documented that as a grievance. Re…	2020-09-01
150	150	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	610	E	1	0	QFLH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to thoroughly investigate falls for two of two sampled residents (1 and 4). Findings include: 1. Review of resident 1's 10/6/17 South Dakota Department of Health (SD DOH) event reporting form revealed: The fall had occurred at 4:30 a.m. The resident's wife had received a call at home from the resident asking her to contact the nurses in the facility, as he needed help. Staff received the call from the wife, and they found him sitting on the floor. Resident first stated he was sitting on his wheeled walker and fell asleep and woke up to falling onto the floor. Then later stated that he was trying to move his wheelchair to the hallway and fell . His left eye was swollen. His wife had taken him to the hospital where he was admitted for weakness, [MEDICAL CONDITION], and fall with periorbital hematoma. They will encourage resident to utilize his wheelchair (if still appropriate) and walker and not to walk on his own. Will keep call light in reach and make sure his cell phone is on his person, so if not within call light reach able to make contact with staff or wife. The administrator's name had been on the final investigation conclusionary summary. There had been no documentation regarding the following investigation areas: -Interviews conducted with the wife or staff members who had been working. -Where the call light had been located. -The last time he had been checked on. -What level of assistance he required. -If the care plan had been followed. -What the environment looked like upon entering the room. -If he had been assisted to bed and who last worked with him. -If there had been any medication changes. 2. Review of resident 4's 11/19/17 South Dakota Department of Health (SD DOH) event reporting form revealed: The fall had occurred at 11:30 a.m. Resident prone on floor beside tipped recliner. He had complained of pain to his left eye brow where an abra…	2020-09-01
151	151	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2017-11-28	658	D	1	0	QFLH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, interview, and policy review, the provider failed to ensure professional standards of practice were followed for one of one sampled resident (1) for: Receipt, transcription, clarification, implementation, re-evaluation, and follow-up to physician's orders. Appropriate nurse documentation of medication when not readily available in the facility versus refused by the resident. Findings include: 1. Review of resident 1's medical record revealed: He had been admitted on [DATE]. His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Disorder of the kidney. -Muscle weakness. -Unspecified dementia. -[DIAGNOSES REDACTED]. -Essential hypertension. He had fallen on 10/6/17 at 4:30 a.m. Review of resident 1's 10/6/17 nursing progress note revealed: At 4:30 a.m. Received call from resident's wife asking for him to be checked on. -Resident called wife from personal cell phone and told her he needed help. -Resident checked on and found sitting on the floor. -Resident first stated that he was sitting on his wheeled walker and fell asleep but woke up as he was falling on the floor. -Then later stated that he was trying to move his wheelchair to the hallway and fell . -Noticed left eye was swollen. -No other injuries noted. -Vitals, range of motion, and neuro (signs) checked. -Doctor and spouse notified of event. --There had been no documentation regarding the recommendation from the physician regarding the resident hitting his head. At 9:39 a.m. Residents wife here with resident this AM. States that she called (physician's name) regarding fall this AM and plans to take resident to the (hospital name) ER (emergency room ) and to see (physician's name). At 10:05 a.m. Resident to (hospital name) ER via private vehicle accompanied by wife. Meds (medication) sent with. *At 11:47 a.m. (Physician's name) updated that resident was taken to (hospital name) ER to see (another physicia…	2020-09-01
152	152	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	584	E	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the provider failed to maintain and repair three of four sampled residents' rooms (117, 121, and 125) for the following: Paint walls after plaster had been repaired in rooms [ROOM NUMBER]. Repair chipped and broken sheetrock in rooms [ROOM NUMBERS]. Repair wood that was splintering in room [ROOM NUMBER]. Clean the showers in room [ROOM NUMBER] and 125. Stop leaking shower hose that caused a thick, slime to the floor of the shower in room [ROOM NUMBER]. Findings include: 1a. Observation on 12/9/19 at 4:04 p.m. of resident room [ROOM NUMBER] revealed: There was a piece of wood attached to the wall at the head of his bed. The piece of wood was splintered in areas. b. Observation on 12/9/19 at 4:21 p.m. of resident room [ROOM NUMBER] revealed: On the wall beside the bed there were white, unpainted drywall patches the length of the bed. In the shower there was a wheelchair (w/c). -The resident said was not hers. The hose to the shower was hanging with the shower head not attached to it. -There was water dripping from the hose to the floor. -There was a dark brown color on the floor with a clear slimy substance on it from where the hose was leaking and going to the drain. -There was a dead moth laying in the slimy substance. c. Observation on 12/10/19 at 11:22 a.m. of resident room [ROOM NUMBER] revealed: There was paint scraped off the wall by the head of his bed with several different colors showing through. The corner of the wall outside the shower had broken drywall from the floor up approximately one foot with crumbling pieces on the floor. All the corners in the room had broken drywall and scraped paint revealing the bare metal corner pieces. The toilet room had holes in the wall and the entire area if a vent covered in rust. *His shower room had the following in it: -Three w/cs. -Four, one gallon containers on the floor. -A w/c seat cushion on the floor. -Blankets and an ankle-foot orthosis w…	2020-09-01
153	153	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	604	D	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to complete a physical restraint assessment for one of two sampled residents (28) that had restraint devices being used. Findings include: 1. Review of resident 28's medical record revealed she: Had been admitted on [DATE] after being discharged from the hospital. Had the following Diagnoses: [REDACTED]. Had a Brief Interview for Mental Status assessment score of three indicating a severe cognitive impairment. Observation and interview on 12/9/19 at 4:21 p.m. with resident 28 revealed: She was able to recall her name, the name of the facility she was in, approximately how long she had been in the facility, and the situation that had brought her to the facility. When asked about falls she said she had falls before she came to the facility but none since she had came here. She was laying in her bed with something clipped to her shirt, and a cord that led to under her body. She said it was to keep her from falling, because if she got up it would make a noise so she could get help. She said it was on her all the time and not just when she was in her bed. Her bed was in the lowest position. There was a geriatric (geri) chair in the corner of the room with a tray leaning against it. -She said those items were not hers. Observations revealed a personal alarm device was on resident 28 at the following dates and times: 12/10/19 at 9:31 a.m. she was in her bed. 12/10/19 at 1:17 a.m. she was in her bed. 12/10/19 at 2:27 p.m. she was in her bed. Review of the matrix care report with a last reviewed/revised date of 11/22/19 obtained from the Minimum Data Set (MDS) coordinator for resident 28 revealed: She stated what was on line was not updated, and this was the most up to date care plan. *In handwriting on the last page were the following approaches:-Geri-chair (with lap) tray. Laptray on while in Geri chair. To be removed every 2 (hours) for 10 (minutes)…	2020-09-01
154	154	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	609	D	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the provider failed to ensure a fall with injury was reported to the South Dakota Department of Health (SD DOH) in a timely manner and a thorough investigation had been completed for one of three sampled residents (38). Findings include: 1. Review of resident 38's medical record revealed: She had been admitted on [DATE]. Her [DIAGNOSES REDACTED].>-Muscle weakness. -History of falling. -Repeated falls. -Major [MEDICAL CONDITION], single episode. She had a fall on 11/17/19, hit her head, and was sent to the emergency room . Review of resident 38's 11/22/19 Minimum Data Set (MDS) assessment revealed: Her Brief Interview for Mental Status assessment score was six indicating her cognition was severely impaired. She required extensive assistance from one staff member for bed mobility, transferring, dressing, toilet use, and personal hygiene. She had a fall with injury since her last assessment on 11/11/19. Interview on 12/11/19 at 11:26 a.m. with the director of nursing regarding resident 38 revealed: They had not sent in a final report to the SD DOH regarding the investigation into her fall on 11/17/19 until this morning. They were sending in another report and noticed they had not sent in a final report. They had sent in other reports in between 11/17/19 and 12/11/19. Review of resident 38's 12/11/19 SD DOH final report revealed: The fall had occurred on 11/17/19. The documentation stated she took herself to the bathroom, but that conflicted with her MDS assessment. They had not completed an investigation into the fall. All the documentation in the report was of nursing notes from the time of the fall and after. There was no documentation of what had occurred prior to the fall, when the resident had last been assisted, or if the care plan had been followed. Review of the provider's undated Abuse policy revealed: Investigation of abuse situations is critical. The investigation p…	2020-09-01
155	155	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	657	D	0	1	DTNP11	Based on interview and record review, the provider failed to ensure 1 of 14 sampled residents (22) care plans was updated to reflect the resident's recurring pressure ulcers. Findings include: 1. Review of resident 22's medical record revealed he had recurring pressure ulcers. Pressure ulcers had not been addressed on his current care plan. Refer to F686, finding 1.	2020-09-01
156	156	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	658	E	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure: Parameters for blood glucose (sugar) levels were defined for one of one sampled resident (35) who had excessively high levels. physician's orders [REDACTED]. One of one sampled resident (22) who had weight fluctuations was re-weighed according to the provider's policy. Vital signs and neurological (neuro) assessments were completed after a fall with a head injury for one of two sampled residents (13). Findings include: 1a. Review of resident 35's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Dependence on [MEDICAL TREATMENT]. -Dependence on supplemental oxygen. -Type 2 diabetes with mild nonproliferation diabetic retinopathy without [MEDICATION NAME], unspecified eye. -[MEDICAL CONDITION], unspecified. -Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. His Brief Interview for Mental Status (BIMS) assessment score was fifteen indicating his cognition was intact. Interview on 12/10/19 at 10:29 a.m. with resident 35 revealed he had problems with his blood sugar. He said at least once per week his blood sugar crashed. When questioned further he was not able to explain what that meant. Review of resident 35's blood glucose levels from 10/1/19 through 12/10/19 revealed: His blood glucose levels were over 300 milligrams per deciliter (mg/dL) for the following: -October: 28 out of 122 times. -November: 36 out of 119 times. -December to date: 9 out of 39 times. --His blood glucose levels were over 450 mg/dL for 16 out of those 73 times there were over 300 mg/dL. *On 10/10/19 he had blood glucose levels under 50 mg/dL two times that day. Review of resident 35's physician's orders [REDACTED]. Review of resident 35's 11/25/19 care plan revealed he had one intervention that stated: (Resident name) will often have very high blood sugars. Call PCP (primary care physician) or on call MD (medical doctor) and noti…	2020-09-01
157	157	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	686	G	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure pressure ulcers were consistently monitored and documented, effective interventions were in place and updated, and the physician was notified of new opened areas for one of one sampled resident (22) who had recurring pressure ulcers. Findings include: 1. Review of resident 22's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Muscle weakness. -Constipation. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Heart failure. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -Chronic lymphocytic [MEDICAL CONDITION] of B-Cell type in remission. -[MEDICAL CONDITION]. -Hypertension. -[MEDICAL CONDITION]. Review of resident 22's 7/24/19 Minimum Data Set (MDS) assessment revealed: His Brief Interview for Mental Status (BIMS) assessment score was eleven indicating his cognition was moderately impaired. He required extensive assistance from one staff member for bed mobility, transferring, dressing, toilet use, and personal hygiene. He was not at risk for developing pressure ulcers. However he currently had one, stage two, facility acquired pressure ulcer. The skin and ulcer treatment interventions were: -Pressure reducing device in his bed and chair. -Nutrition and hydration intervention to manage skin problems. -Pressure ulcer care. -Application of ointments/medications other than to feet. Review of resident 22's 10/20/19 MDS assessment revealed: His BIMS assessment score was twelve indicating his cognition was moderately impaired. He required extensive assistance from one staff member for toileting and personal care. He was at risk for developing pressure ulcers. He did not currently have a pressure ulcer. He had moisture associated skin damage. *The skin and ulcer treatment interventions were: -Pressure reducing device in his bed and chair. -Nutrition and hydration intervention to manage skin problems. -Ap…	2020-09-01
158	158	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	689	G	0	1	DTNP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to assess and monitor one of one sampled resident (37) who was at risk for coffee burns. Findings include: 1. Observation on 12/9/19 at 5:24 p.m. revealed resident 37 was seated in his wheelchair in the dining room with an enclosed coffee mug. It was in a holder on the right side of his wheelchair (w/c). Interview on 12/10/19 at 8:46 a.m. with registered nurse C regarding resident 37 revealed he had a burn on his upper, right outside leg area due to spilling hot coffee. He had informed her he had switched his coffee from his mug to a paper cup. The coffee had spilled out of the paper cup. Review of resident 37's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of resident 37's 3/5/19 annual Minimum Data Set (MDS) assessment and his 11/22/19 quarterly MDS assessment revealed: His Brief Interview of Mental Status (BIMS) assessment score was fifteen indicated he was cognitively intact. He had no behaviors. He had upper extremity impairment on one side. He was independent with eating after set-up assistance. His quarterly MDS progress note revealed: -He was alert with intermittent confusion. -Both his legs had scattered scabbed over areas and very dry skin. -He used a w/c to propel himself around his room and the facility. -He was independent with eating after set-up help. Review of resident 37's culinary service progress notes revealed: On 5/29/19: he had a cup of coffee on his w/c that he drank from all day. On 8/22/19: he drinks a lot of coffee throughout the day. Review of resident 37's 11/19/19 mini-nutritional assessment revealed: He drank greater than five cups a day of fluid (water, juice, coffee, tea, and milk). He fed himself with some difficulty. He drinks coffee continually no way to measure how much fluid he is getting as multiple people fill his cup during the day. Review of resident 37's nursing pro…	2020-09-01
159	159	TEKAKWITHA LIVING CENTER	435038	6 E CHESTNUT	SISSETON	SD	57262	2019-12-11	812	E	0	1	DTNP11	Based on observation and interview, the provider failed to ensure two of two Manitowac water/ice machines were maintained in a clean, operable condition. Findings include: 1. Observation on 12/9/19 at 5:51 p.m. of the Manitowac water/ice machine in the north dining room revealed a large amount of mineral (lime) build-up on the surface, catch grate, and catch tray of the machine, and on the stainless steel table. Observation on 12/9/19 at 5:53 p.m. of the Manitowac water/ice machine in the hallway by the kitchen revealed mineral (lime) and rust build-up on water catch tray grate of the machine. Interview on 12/11/19 at 3:15 p.m. with the maintenance supervisor confirmed the above observations. Further interview revealed cleaning of both water/ice machines was not on the preventative maintenance schedule. Interview on 12/11/19 at 3:30 p.m. with the dietary service manager revealed the water/ice machines were not on dietary's cleaning schedule.	2020-09-01
160	160	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	600	H	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to: Provide necessary care in services resulting in neglect and resident-to-resident altercations for two of two sampled closed resident record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit (MCU). Implement a resident-specific care plan that included evaluations and revisions of interventions to prevent abuse and neglect for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Provide supervision and monitoring of the delivery and implementation of care for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Ensure effective communication between nursing and direct care staff and health care providers regarding physical and verbal abuse for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. Contact the primary physician at the time of an acute change in condition that required the plan of care to be revised to meet the residents' needs in a timely manner for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. Ensure staff responded professionally to medical and psychiatric emergencies for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. *Ensure thorough orientation upon hiring for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Review of a So…	2020-09-01
161	161	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	609	E	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to: Ensure the South Dakota Department of Health had been notified of reportable incidents for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment. A thorough investigation had been completed for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired with reportable incidents. Findings include: 1. Review of resident 1and 2's closed records and residents 3, 4, and 5's active medical records and investigation reports revealed: The residents had been subject to falls and resident-to-resident altercations. The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). All reviewed events had not been thoroughly investigated to: -Discover the cause of the event. -Implement safeguards to prevent further potential abuse. 2. Review of the provider's 8/17/17 Care Plans - Comprehensive policy and procedures revealed: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: -a. Incorporate identified problem areas; -b. Incorporate risk factors associated with identified problems; -d. Reflect the resident's expressed wishes regarding care and treatment goals; -g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; *6. Identifying problem areas and their causes, and developing …	2020-09-01
162	162	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	610	H	1	0	Z0T511	> Based on record review, interview, and policy review, the provider failed to ensure a thorough investigation had been completed and documented for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired and had been subject to resident-to-resident altercations. Findings include: 1. Review of resident 1, 2, 3, 4, and 5's medical records revealed: They had been subject to resident-to-resident altercations. Thorough investigations had not been documented and maintained. *The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). Refer to F600, F609, F657, F658, F726, F744, F745, and F842.	2020-09-01
163	163	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	657	E	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to ensure care plans were updated to reflect individual needs and interventions for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: 1. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed:For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-six of thirty days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-six of thirty days. --Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behaviors. For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-one of thirty-one days. --Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. *For (MONTH) 1 through (MONTH) 15, (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for nine of fifteen days. Of those days the wandering behavior had: --Significantly intruded on the privacy or activities of others for nine of fifteen days. -On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. --There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. -The (MONTH) 1 to 15 from 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. --There was no further documentation in the medical record regarding what had prompted th…	2020-09-01
164	164	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	658	G	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure two of two closed resident records (1 and 2) who had cognitive impairment and resided on the memory care unit (MCU): Had notified the residents' (1 and 2) physicians of significant changes as required. Had provided appropriate emergency response for one of one sampled resident (1) with a fall with a major injury. Had identified, assessed and documented specific targeted behaviors for both residents. Reviewed and modified the interdisciplinary care plans to identify specific interventions to address behavioral and mood-related symptoms for both residents. Findings include: 1. Observation on 3/8/18 at 1:00 p.m. of an undated and unsigned note posted at the Warren unit nurses' station revealed: (Medical director's name) and his team DO NOT want to receive faxes!!! If it is important and needs to be addressed right away you need to call him. If it can wait, then write out a fax and put it in the medical records folder (at each nurses station) and (medical records staff name) will get it to him when he comes out that week. Observation on 3/8/18 at 1:00 p.m. of an undated Charting guidelines posted at the Warren unit nurses' station revealed: Chart any behaviors as an IPN note. If behavior needs to continue to be monitored put on pass along to chart for two to three days. Event report: front and back fully completed, call family, fax MD, IPN Note. Surveyor: 2. Review of resident 1's 2/22/18 resident transfer form had indicated: The resident's name. She was a female. Date of the transfer was 2/22/18. Payment source was Other. Under vitals at time of transfer: Could not. Too worked up. Speech and mental impairments had been checked. Additional pertinent information indicated Has dementia on locked unit. The above form had not indicated: -The name of the physician or facility transferring from. -The name of the f…	2020-09-01
165	165	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	679	F	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, interview, policy review, and job description review, the provider failed to ensure an individualized activity program had been provided for two of two sampled resident closed records (1 and 2) and three of three sampled residents (3, 4, and 5) in the memory care unit (MCU). Findings include: Surveyor: 1. Observation and interview on 3/6/18 at 3:00 p.m. in the MCU revealed certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) K sat at a table with two residents. There were two magazines on two different tables. The residents sat but were not looking through magazines or participating in other activity. Interview with CNA/UAP K at that time revealed: She mainly worked alone from 6:00 a.m. until 6:30 p.m. Maybe three times per week there was another staff member working with her from 6:00 a.m. until 2:30 p.m. An activity calendar was attached to the wall in the social area. The calendar indicated the activities for the afternoon were: -A bible study at 1:30 p.m. -Bingo at 2:30 p.m. -Coffee and snack at 2:30 p.m. -Card Club at 4:30 p.m. When questioned about the activities listed on the calendar CNA/UAP K stated the calendar was for the residents who resided outside of the memory unit. -The memory care unit residents did not follow that calendar. One or two of the memory care unit residents attended some of the off-unit activities. She stated the activity staff came to the memory unit maybe three times per week for an activity. The activity staff did provide some activity items such as [MEDICATION NAME] and paper. It was difficult for her to conduct activities alone while caring for the residents. Surveyor: 2. Observation on 3/6/18 from 4:10 p.m. through 4:15 p.m. in the MCU revealed: There were: -Four residents sitting at a table. -CNA/UAP [NAME] was sitting at the table visiting with two of the residents. -The other two residents at the table were sitting there without any staff…	2020-09-01
166	166	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	726	G	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, personnel file review, job description review, and policy review, the provider failed to ensure an orientation program had been completed for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Interview with the DON, infection control nurse (ICN)/staff development, and licensed social worker (LSW) on 3/6/18 at 2:30 p.m. revealed: The current census for the memory care unit (MCU) was nine. They could have up to thirteen residents in the MCU. The usual staffing pattern for the MCU consisted of: -Two staff on the day shift from 6:00 a.m. through 2:30 p.m. -One staff on the evening shift from 2:00 p.m. through 6:00 p.m. -One staff member on the night shift from 6:00 p.m. through 6:30 a.m. -They usually worked twelve hour shifts. -Someone from the Warren wing would go back to cover breaks for the MCU person. -One nurse covered the Warren wing and MCU. -They usually had an UAP for the MCU. 2. Review of licensed practical nurse (LPN) B's personnel file revealed: A hired date of 1/17/18. There was no documentation of a competency checklist in her file. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding her orientation revealed: She had started on 1/17/18. She worked the day shift from 6:00 a.m. through 6:30 p.m. She mostly worked on the Warren wing and the MCU. Her orientation had consisted of medication pass, documentation, and had not sat down side-by-side with the other nurse training her. If she had issues she could have called another nurse. She had received a little training on dementia. She had the orientation competency checklist in her backpack in her car. She had three days of orientation on the floor. She had been hired to work on Center but was on Warren. She thought she had been hired to replace LPN A to get her off the floor and into an office job. LPN A had been her mentor. *She had learned about the resid…	2020-09-01
167	167	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	744	H	1	0	Z0T511	> Based on observation, interview, record review, policy review, and job description review, the provider failed to: Provide the necessary care and services for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment to reach his/her highest practicable level of physical, mental, and psychosocial well-being. Develop policies and procedures for all residents residing on the memory care unit (MCU). Develop a care plan with measurable goals and interventions to address the care and treatment for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who had cognitive impairment. Identify, document, and communicate specific targeted behaviors for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) residing on the MCU. Ensure staff had the skills and qualifications to assess residents' with behaviors for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: Surveyor: 1. Interview on 3/13/18 at 10:46 a.m. with the director of nursing (DON) and the administrator regarding policies and procedures revealed the provider had: A policy regarding admission criteria for the MCU. No policies and procedures specific for the care of the residents residing on the MCU. Surveyor: Review of the provider's (YEAR) Dementia - Clinical Protocol policy revealed: Assessment and Recognition: -1. The physician will help identify individuals who have been diagnosed as having dementia or otherwise irreversibly impaired cognition. -5. The staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. -6. The staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complica…	2020-09-01
168	168	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	745	F	1	0	Z0T511	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, interview, policy review, and job description review, the provider failed to identify and promote individualized approaches to care that meet the mental and psychosocial needs for two of two closed resident records(1 and 2)and three of three sampled residents (3, 4, and 5). Findings include: 1. Review of resident 2's medical record revealed: An admission date of [DATE]. [DIAGNOSES REDACTED]. The 9/8/17 admission Minimum Data Set (MDS) assessment indicated his Brief Interview for Mental Status (BIMS) score had been a four indicating severe cognitive impairment. Review of resident 2's behaviors documented by the certified nursing assistant (CNA) staff in the behavior tracking reports and by the nursing staff in the interdisciplinary progress notes (IPN) revealed: For (MONTH) (YEAR): -On 12/24/17 at 5:35 p.m. registered nurse (RN) O documented on resident 1's fall report that resident 2 was standing near her and said If you don't move I will back into you. CNA D reported to nurse that he did back into her causing her to lose her balance. --There were no behaviors documented in the behavior report and/or the IPN. -There was no facility and Department of Health (DOH)event report completed for this date. *For (MONTH) (YEAR): -On 1/5/18 at 7:30 p.m. CNA L documented physical altercation with staff and resident, hitting or trying to hit them. The staff and resident names were not identified. -On 1/16/18 at 9:45 a.m. CNA D documented Resident threatened another resident, said several times that if this particular resident came near him again he would knock her out and throw her into the river. The resident was not identified. -On 1/19/18 at 7:00 p.m. CNA K documented Hit res (resident) in left breast. The resident was not identified. -On 1/20/18 at 1:43 p.m. CNA/unlicensed assistive personnel (UAP) [NAME] documented Resident is very aggressive to others. -On 1/21/18 at 3:38 p.m. CNA L documented resident went…	2020-09-01
169	169	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-03-13	842	E	1	0	Z0T511	> Based on record review, interview, and policy review, the provider failed to ensure accurate documentation in the medical record for two of two resident closed records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: Surveyor: 1. Interview on 3/13/18 at 10:46 a.m. with the director of nursing regarding charting and documentation revealed she: Stated the certified nursing assistants (CNA) were documenting resident behaviors on the trend tracker. Was not sure if the CNAs had been reporting the behaviors to the charge nurse for assessment. Agreed the facility event reports were incomplete with: -Dates. -Signatures. -Pertinent information. Confirmed other facility event reports had not been completed at the time of the incidents. Confirmed interdisciplinary progress note documentation had not been complete. Surveyor: Review of the provider's (MONTH) (YEAR) Charting and Documentation policy revealed: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 3. All incidents, accidents, or changes in the resident's condition must be recorded. 7. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: -a. The date and time the procedure/treatment was provided; -c. The assessment data and/or any unusual findings obtained during the procedure/treatment; -f. Notification of family, physician or other staff, if indicated; -g. The signature and title of the individual documenting. Refer to F600, F609, F610, F657, F658, F679, F726, F744, and F745.	2020-09-01
170	170	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	226	D	0	1	80K911	Based on record review, interview, and policy review, the provider failed to ensure two of six sampled residents (2 and 16) with incidents requiring an investigation had them completed and documented thoroughly. Findings include: 1. Review of a 5/16/17 Grievance/Event Report for resident 16 revealed: Report of Event: (First name of family member) was concerned about bruising on (resident name) forearms and elbows. Witness to Event: Left blank. Completed by: Signed by licensed social worker (LSW). Date of event: 5/16/17; Time: Left blank. Investigation: Discussed with CNAs (certified nursing assistant), restorative staff and nurses. Determined that there could be 3 sources 1) arm rest of w/c (wheelchair), 2. happening during transfers with lift or 3. While using parallel bars in therapy. Follow Up Actions of Resolve: 1. Sheepskin was ordered to pad w/c arms. 2) & 3) Staff was instructed to be mindful of position of res (resident) arms during transfers and while using parallel bars. The investigation did not include: -Names of staff they interviewed. -How they reached the conclusion for the follow-up action. -What occurred during transfers with the lift or using the parallel bars that might have caused the bruising. -Was there something the staff were or were not doing that warranted them being mindful when using the lift or parallel bars. Interview on 8/2/17 at 1:45 p.m. with the director of nursing regarding resident 16's above bruise investigation revealed: They did not have additional documentation of the investigation into that event. She confirmed there was missing information in that investigation. Review of the provider's Abuse Neglect and Exploitation-Clinical Protocol policy revealed: 1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source, the Nurse Supervisor on duty must complete and (an) event form and record such information into the resident's clinical record. 3. Documentation shall include information relevant to risk factor…	2020-09-01
171	171	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	281	D	1	0	80K911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, interview, and policy review, the provider failed to ensure professional standards were followed for the documentation of one of one sampled resident (14) who had a change in condition. Findings include: 1. Review of resident 14's medical record revealed: A [DATE] admitted . Diagnosis: [REDACTED]. He had an indwelling Foley catheter. He had been on hospice services at the facility. The hospice services had been discontinued on [DATE] related to stabilization in his medical condition. He was hospitalized in the intensive care unit on [DATE] after a change in condition. His catheter was changed in the emergency room due to being plugged. He had a large amount of bloody urine output after the new catheter was inserted. He was given three intravenous antibiotics in the emergency roiagnom on [DATE] for the [DIAGNOSES REDACTED]. He was transferred to a hospice facility after the hospitalization and expired on [DATE]. Review of resident 14's [DATE] physician's orders [REDACTED].>Change number 16 french Foley with 10 cubic centimeters (cc) balloon the first of the month and as needed (PRN). [DIAGNOSES REDACTED]. Review of resident 14's (MONTH) (YEAR) and (MONTH) (YEAR) treatment records revealed there was: Documentation his Foley catheter was changed on [DATE] and on [DATE] for the monthly changes. Documentation his Foley catheter was changed on [DATE] as it had been leaking with no urine output in the drainage bag. No documentation of any difficulties with the above Foley catheter changes. Review of resident 14's [DATE] nursing progress notes by registered nurse (RN) D revealed: *12:41 p.m.; Contact made with daughter. Resident leans to right when in wheelchair. Does not have equal strength in both hands. Does respond to staff. Blood pressure (B/P) ,[DATE], pulse 100 and irregular. Respirations 20. Oxygen applied at 2 liters per nasal cannuala and saturation 90 percent (%). Daughter states will be out shortly …	2020-09-01
172	172	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	309	D	0	1	80K911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure a complete assessment of possible causing factors of falls for one of one sampled resident (3) with multiple falls. Findings include: 1. Random observations from 7/31/17 at 3:00 p.m. through 8/2/17 at 11:00 a.m. of resident 3 revealed she: Resided in the secured memory care unit (MCU). Could verbally communicate her needs. Was confused but oriented to herself, the situation; her long and short term memory were impaired. Used a wheelchair for mobility around the unit. Was able to tell the staff when she needed to go to the bathroom. Frequently laid down in her bed between meals. -Her bed was in a low position, and the door to her room was closed. Interview on 7/31/17 at 4:30 p.m. with certified nursing assistant (CNA) C regarding resident 3 revealed: She was able to tell the staff when she needed to go to the bathroo,. She repeatedly requested to go to the bathroom. -Sometimes they would take her to the bathroom, and she would immediately ask to go again. --She would spend a lot of time in the bathroom feeling the need to go. Review of resident 3's 7/30/17 physician's orders [REDACTED]. That order had been started on 4/10/16. Interview of CNA B on 8/1/17 at 9:00 a.m. revealed: She had started working in the facility on 7/24/17. It was her first day in the MCU. She did not recall specific training for working with residents with dementia but had previously worked in a MCU in another facility. Observation on 8/1/17 at 9:55 a.m. of CNA B regarding resident 3 revealed: The resident had been sitting in the day room and stated she needed to go to the bathroom. The resident wheeled herself to her room with CNA B going with her. CNA B pushed her wheelchair up to the bathroom door of the resident's room and because it was a large wheelchair it would not fit in the bathroom. *The resident said she could stand up by grabbing the sink to then sit…	2020-09-01
173	173	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2017-08-02	441	E	0	1	80K911	Based on observation, interview, manufacturer's instructions review, and policy review, the provider failed to ensure appropriate disinfection of residents' rooms by one of two (A) observed housekeepers. Findings include: 1. Observation and interview on 8/1/17 at 8:50 a.m. of housekeeper A cleaning a resident's room in the center hallway revealed she: Had worked there for two years as a housekeeper. Was one of two housekeepers working that day and would clean half of all of the residents' rooms. Performed hand hygiene and gloved. Emptied the garbage cans and dusted the room. Sprayed the toilet and bathroom surfaces with 3M Non-Acid disinfectant and cleaned the toilet bowl. Sprayed Clorox Fuzion onto a dry cloth, then added some Provon hand wash from the wall dispenser, and proceeded to wipe down the sink and countertop with that. Went back into the bathroom to wipe off the toilet and surfaces with a clean cloth. Five minutes had passed since spraying on the disinfectant. Finished cleaning the room. Stated she would always clean a room that way. Review of the manufacturer's instructions for 3M Non-Acid disinfectant revealed it took ten minutes to adequately disinfect surfaces. Review of the provider's undated procedure for Routine Room Cleaning revealed: Cleaning solution. (Follow directions on label.) No mention of what product was to be used nor the time it needed to be left on to adequately disinfect surfaces. Interview on 8/2/17 at 9:30 a.m. with the director of maintenance and housekeeping regarding housekeeper A's cleaning of residents' rooms revealed he: Agreed the 3M Non-Acid disinfectant took ten minutes on surfaces before being wiped off to adequately disinfect. Was unsure why she used the Clorox and Provon products together to clean the sink. Was unaware in the above policy there was no mention of the product used nor the time it needed to be left on surfaces to disinfect them. Interview on 8/2/17 at 11:40 a.m. with the director of nursing and the infection control nurse regarding disinfec…	2020-09-01
174	174	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-08-08	610	E	1	0	25711	> Based on observation, interview, record review, and policy review, the provider failed to ensure three of three sampled residents (1, 3, and 4) had a thorough investigation completed for the following incidents for a resident fall with an injury, staff-to-resident abuse allegation, and a resident-to-resident abuse allegation. Findings include: 1. Interview on 8/8/19 at 9:15 a.m. with certified nursing assistant (CNA) C regarding resident 3 revealed she: Had just returned from vacation. Was not aware of the current fifteen minute checks related to a resident-to-resident incident that had occurred on 8/6/19 at 1:30 p.m. between resident 3 and another resident. Was unsure if the pocket care plan indicated the fifteen minute checks. Had not completed any fifteen minute checks today. Review of resident 3's 8/6/19 through 8/8/19, 15 Minute Check documentation sheet on 8/8/19 at 9:20 a.m. revealed: There were multiple areas on the document that were not completed. On 8/7/19 there was no documentation from 3:00 p.m. through 9:45 p.m. On 8/8/19 there was no documentation from 6:45 a.m. through 9:30 a.m. Observation on 8/8/19 from 9:35 a.m. through 10:00 a.m. of resident 3 revealed: The resident was sitting in his wheelchair in front of the television in the dining room. He was slumped over sleeping. Writer introduced herself with no response from the resident. He was unable to verbalize any response to questions asked. There was an unidentified staff person that came into the dining room to check on the resident at 10:00 a.m. Review of resident 3's 8/8/19, 15 Minute Check documentation sheet on 8/8/19 at 10:05 a.m. revealed the previous blank areas identified above were now completed and filled in from 6:45 a.m. through 10:45 a.m. Review of resident 3's current pocket care plan revealed there was no documentation related to his fifteen minute check interventions. Those interventions had been put in place on 8/6/19 after the resident-to-resident incident to ensure direct care staff were aware of the fifteen m…	2020-09-01
175	175	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-08-08	842	E	1	0	25711	> Based on observation, interview, record review, and policy review, the provider failed to ensure three of six sampled residents (1, 3, and 4) had thorough documentation of investigations related to staff-to-resident abuse, resident-to-resident abuse, and a fall with an injury that produced a latent bruise. Findings include: 1. Refer to F610, findings 1, 2, 3, and 4. Review of the provider's undated Charting and Documentation policy revealed: All services provided to the resident or any changes in the resident's medical or mental condition should have been documented in the resident's medical record. All incidents, accidents, or changes in the resident's condition should have been recorded. All forms (event, fall, and/or transfer) should have been filled out in its entirety. There was no clear direction in the policy and procedure for complete and thorough investigation documentation.	2020-09-01
176	176	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-08-29	565	E	0	1	81NC11	Based on record review and interview, the provider failed to follow-up on resident council concerns regarding baths not being done with resolution of that issue. Findings include: 1. Confidential interview on 8/28/18 at 1:00 p.m. with a group of residents revealed: Baths had not always gotten done on the days they were scheduled. One resident stated she was on the schedule for a bath yesterday but had not gotten it. -She had gotten one today. Sometimes the bath aides got pulled to work on the floor and would not have time to give baths that day. If staff called in sick they would not get baths that day. The hallway with the most concerns was the east hall. Review of the resident council minutes from 4/18/18 through 7/23/18 revealed: On 4/23/18 and 7/23/18 the residents had concerns about not getting baths. There had been no resolution or follow-up regarding baths not being done documented in (MONTH) (YEAR). -The follow-up in (MONTH) (YEAR) had been No lingering concerns. There had been no documentation of investigations into the concerns regarding baths not being done for (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR). Interview on 8/29/18 at 10:54 a.m. with the activity director revealed: She attended the resident council meetings. She typed up the minutes for those meetings. The follow-up with residents on if the issue had improved had not been documented. She had not known she was supposed to document resolutions of concerns in the resident council minutes. Interview on 8/29/18 at 11:11 a.m. with the administrator revealed: They had completed response forms for the above mentioned concerns that came out of the resident council meetings that had stated they were hiring staff. She was not aware the activity director had not been providing resolution to the resident council. *She agreed they had not investigated the issue of baths not getting done when they had been brought up in the meetings.	2020-09-01
177	177	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-08-29	684	E	0	1	81NC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to ensure one of three sampled residents (53) with diabetes received proper care and nutrition to avoid [MEDICAL CONDITION]. Findings include: 1. Review of resident 53's complete medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. He had a Brief Interview of Mental Status score of four. Indicating his cognition was severely impaired. He was grieving the loss of his wife. -She had passed away in (MONTH) (YEAR). He received the following medications for diabetes: -[MEDICATION NAME] 20 milligrams (mg) twice a day. --It was decreased to 10 mg twice a day on 8/27/18. -[MEDICATION NAME] 1000 mg twice a day. He received the above medications in the a.m. and at supper/dinner time. He had his blood sugar checked four times a day at: 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. Parameters to call the physician if the blood sugar was greater than 400 or less than 70. Review of resident 53's 7/28/18 care plan revealed: He had a potential for hyperglycemic or hypoglycemic episodes secondary to diabetes. Blood sugar would be within a range of 80 to 120. He would have relief of the episode within thirty minutes of interventions. Interventions listed were: -Labs as ordered, report abnormal findings to MD (medical doctor) with follow up as indicated. -Observe for excessive thirst, excessive eating, frequent voiding, change in level of consciousness, perspiration, fatigue, nausea/vomiting, tremors, provide interventions as per MD order monitor for effectiveness and report to MD if ineffective. -Monitor skin integrity. -Prompt activity attendance and mild exercise daily. -Monitor blood sugar levels per MD order and notify MD of abnormal findings as indicated. --Did not indicate he should have received juice, snack or what measures should have been taken when hypoglycemic episodes were present. --Did not indicate he should have received …	2020-09-01
178	178	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2018-08-29	880	E	0	1	81NC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy review, and manufacturer's recommendations, the provider failed to: Follow manufacturer's instructions for disinfecting resident common use bathroom equipment by two of two observed housekeepers (A and B). Use appropriate hand hygiene during cleaning of resident rooms by one of two observed housekeepers (A). Maintain clean technique for one of four sampled residents (15) who used a Foley catheter bag. Findings include: 1. Observation and interview on 8/28/18 at 10:20 a.m. with head of housekeeping A revealed: She walked out of resident 41's room, discarded her gloves, and without performing hand hygiene she: -Put on a new pair of gloves. -Took a spray bottle with pH7Q Dual Disinfectant from the housekeeping cart. -Entered resident 30's bathroom. -Sprayed the contents of the above disinfectant on the sink. --The sink had a denture cup with tooth paste and an uncovered tooth brush in it. -Sprayed the hand rails and toilet. After ninety seconds she wiped the sink, hand rails, and toilet. With the same gloved hands she: -Put a roll of clear garbage bags on the housekeeping cart. -Returned to the above room and: --Moved the resident's drinking mug to another area on the night stand. --Straightened the papers on the night stand. --Swept the floor, mopped the floor, and placed a wet floor sign in front of the door. --Placed the resident's wheel chair in front of the bed. -Removed her gloves and did not perform any hand hygiene. Interview at that time with head of housekeeping A regarding the use of housekeeping chemicals and isolation procedures revealed: She did not know the contact time of the above disinfectant. She thought it was ten seconds. She was not sure what [MEDICAL CONDITIONS] infection of the bowel was or how to clean if they had it. They used Fuzion for deep cleaning resident rooms. *She thought the contact time for Fuzion was ten seconds. 2. Observation and interview on 8/28/18 at 8:39…	2020-09-01
179	179	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	550	E	0	1	SJ6G11	Based on observation, interview, and policy review, the provider failed to ensure dignity and privacy was maintained while being assisted with personal care and medication administration through an alternative route for three of five sampled residents (11, 31, and 74). Findings include: 1a. Observation and interview on 10/15/19 at 1:34 p.m. of resident 74 revealed: He had: -Been in his room sitting in a wheelchair (w/c) watching television (TV). -A urinary catheter collection bag hanging underneath of the w/c. That collection bag had: -Been full of cloudy and yellow colored urine. -No dignity cover over it and was visible to the staff and visitors walking by in the hallway. He stated: -I'll be going to bingo pretty soon. -I also have a doctor's appointment sometime today too. Observation and interview on 10/15/19 at 3:28 p.m. of resident 74 revealed: He had been sitting in his w/c by the east wing nurses' station. An unidentified staff member offered to assist him back to his room. His urinary catheter collection bag continued to not have a dignity cover over it and was visible to the staff and visitors in that area. Observation on 10/15/19 at 3:31 p.m. with certified nursing assistants (CNA) M and P with resident 74 revealed: The resident had been in his room sitting in his w/c. They had prepared to assist him with personal care and transfer onto his bed. After the CNAs assisted the resident with laying down on his bed CNA M attached his collection bag to the bed frame on the side of his bed. His urine collection bag remained uncovered and visible to all people walking by in the hallway. The CNAs had made no attempt to cover the urine collection bag prior to leaving his room. b. Observation on 10/15/19 at 4:57 p.m. with CNAs M and P with resident 11 revealed: The resident had been laying on his bed sleeping. There had been a large window in his room. The window had no privacy covering over it and faced out towards a large courtyard. *There had been a folded up window blind on the floor propped up a…	2020-09-01
180	180	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	565	D	0	1	SJ6G11	Based on interview, record review, and policy review, the provider failed to ensure residents' concerns voiced in resident council meetings were resolved. Findings include: 1. Interview on 10/16/19 at 10:30 a.m. with members of the resident council revealed: They met monthly with staff assisting in the arrangements of the meetings. -Social worker (SW) W was always present and led the meetings while the activity director took the minutes. -Other staff came to the meeting that represented the department they might be discussing such as the dietary staff would come in to talk about food related issues. There were always food or dietary related concerns including: -Not feeling like their individual concerns were being honored. -They had repeatedly asked for fresh fruit but never received any. -They ran out of coffee on more than one occasion. -In the east dining room they had to wait too long for coffee, because staff would not serve it until they had all the residents in the dining room. -They did not like the small glasses that were used, because they were tippy. -They wanted a salad bar with more items than just lettuce and tomatoes. They were frequently told their dietary requests could not be accommodated, because the item was on back order. SW W was their voice, but they did not feel the concerns were followed-up on. They felt there were always excuses for why their requests were not honored. They did not feel the staff tried to resolve the concern, but that they would tell them why something was not available. The dietary department was well aware of those above concerns. Review of the provider's 10/14/19 through 10/20/19 one week menu cycle revealed a fresh fruit was only indicated once. Interview on 10/16/19 at 3:29 p.m. with dietary managers (DM) A and B revealed: They confirmed there were always multiple concerns about individual food preferences. *For a stretch of time there were financial restraints with the previous owner, so they did not have any food truck deliveries. -There were times they ha…	2020-09-01
181	181	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	584	E	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure a clean and homelike environment was maintained for: Two of three randomly observed floor mats positioned by the residents' (11 and 29) bed. The counter top on one of three nurses' station desk area (east wing). The window coverings in five of ten randomly observed residents' rooms (211, 313, 319, 321, and 327) were in place or good repair. Five of seven randomly observed residents' shared bathrooms (228, 302, 304, 319, and 326) was clean and in good repair. Three of three observed mechanical transfer lifts (east wing and central wing) were clean. One of eight randomly observed resident's (4) wheelchair (w/c) was clean and in good repair. The carpet on one of three wings (east) was clean and in good repair. The ceiling tile on one of three wings (east) was clean and in good repair. Multiple metal brackets holding the ceiling tile in place for one of three wings (east) had cleanable surfaces. Three of four observed exit doors on one of three wings (east) were clean. Three of six randomly observed ceiling vents were clean and free from debris on one of three wings (east). Findings include: 1a. Random observations on 10/15/19 from 1:23 p.m. through 2:48 p.m. of residents 11 and 29's rooms revealed: They were both resting in their beds. Their beds were in the lowest position. There were cushioned floor mats on the floor by their beds. -Those floor mats had multiple cracks on the surface of them and exposed the cushioned material inside of them. -Those cracks had created an uncleanable surface for those floor mats. b. Observation on 10/15/19 at 1:34 p.m. of the east wing nurses' station revealed: The counter top on the nurses' desk had multiple chipped areas along the bottom edge. Those chipped areas had exposed the pressed wood underneath of the protective covering. *Those missing chips had created an uncleanable surface for the nurses' station. c. R…	2020-09-01
182	182	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	604	D	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled resident's (11) had assessments and documentation to confirm his movement was not restricted: With the use of a Pummel cushion when sitting in his wheelchair (w/c). When a wedged pillow was placed underneath of his mattress when resting in his bed. Findings include: 1. Observation on 10/15/19 at 2:48 p.m. of resident 11 revealed: He had been: -Laying in his bed sleeping. -Positioned on his left side and was facing the wall. His bed had: -Been pushed up against the wall on the left side. -Been in a low position and was close to the floor. -A floor mat positioned on the floor next to the bed. There had been a wedged cushion placed underneath of his mattress on the right side of his bed. That wedged cushion had: -Been positioned in the middle of the bed. -Created a large raised area behind the resident's lower back and bottom. Review of resident 11's undated pocket care plan information revealed: He was to have a reposition pad in his w/c. His bed was to have been in the low position and a floor mat next to the bed. A foam noodle was to have been placed underneath the mattress. Observation on 10/15/19 at 4:57 p.m. of certified nursing assistants (CNA) M and P with resident 11 revealed: He continued to lay in bed as observed above and had not made any noticeable change in position. The CNAs prepared to assist him with personal care and a transfer from the bed to his w/c. In his w/c was a Pummel cushion that had a raised area. The raised area: -Was located in the middle of the cushion and between his thighs. -Prevented him from scooting forward in the w/c. Interview on 10/15/19 at 5:13 p.m. with CNAs M and P regarding the wedged pillow and Pummel cushion used by resident 11 revealed: They confirmed the resident had a history of [REDACTED]. The wedged cushion was used to keep him from falling out of his bed. CNA P stat…	2020-09-01
183	183	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	610	E	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, policy and procedure review, the provider failed to ensure a thorough investigation had been completed and documented for two of two sampled residents (34 and 73) who had a fall with injury. Findings include: 1. Review of resident 73's medical record revealed: admission date of [DATE]. She had been admitted on Medicare part A/skilled nursing. She had been receiving occupational therapy (OT) and physical therapy (PT) services with a goal to return home. The undated Admission Observations flow sheet stated she required assist of 2 with transfers. Review of the admission 9/5/19 Minimum Data Set (MDS) assessment for resident 73 revealed: A Brief Interview for Mental Status assessment score of fourteen indicating she was cognitive. She required: -Extensive assistance of two staff members with transfer and toilet use. -Limited assistance of one staff member with ambulation. Interview on 10/16/19 at 4:03 p.m. with resident 73 revealed: She had gone to the hospital on [DATE] from her own home, because she woke up and could not walk. They sent her to the nursing home around 9/1/19 for occupational therapy and physical therapy. On 9/14/19 a staff member had been assisting her to the bathroom. -They had placed a gait belt on her and were assisting her with the walker. -The staff member let go of her, walked around her, and opened the bathroom door. -She fell backwards to the floor hitting the back of her head. -They sent her to the hospital. -She ended up with a bump to the back of her head and had broken her right collar bone. -She would be resuming therapy services on 10/23/19. Continued interview on 10/17/19 at 10:30 a.m. with resident 73 regarding her fall on 9/14/19 revealed the same story as she had said above. Review of the South Dakota Department of Health required healthcare facility event reporting final report for resident 73 revealed:Cognition score of fourteen indicating she was cognitive. *Brief…	2020-09-01
184	184	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	641	D	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and manual review, the provider failed to ensure one of two sampled residents (58) who required [MEDICAL TREATMENT] services three times a week had been accurately recorded on the Minimum Data Set (MDS) assessment. Findings include: 1. Review of resident 58's medical record revealed: She was admitted on [DATE]. Her primary admission [DIAGNOSES REDACTED]. She had required [MEDICAL TREATMENT] services for her [MEDICAL CONDITION] three times a week. Her most recent 9/13/19 quarterly MDS was coded to support she had not required any [MEDICAL TREATMENT] services. -The 9/23/19 nursing summary of that MDS had not supported the need for [MEDICAL TREATMENT] services three times a week. Observation and interview on 10/16/19 at 10:24 a.m. with resident 58 revealed she: Had been in her room resting in the recliner. Was alert, oriented, and capable of making her needs known. Stated: -I just got back from [MEDICAL TREATMENT], so I'm resting a bit. -I go every Monday, Wednesday, and Friday. Had a shunt for [MEDICAL TREATMENT] placed in her upper left arm. Interview on 10/16/19 at 10:31 a.m. with registered nurse (RN) R regarding resident 58 revealed he: Confirmed the resident went for [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Would have assessed her shunt site on the days she went out for [MEDICAL TREATMENT]. Interview on 10/17/19 at 10:35 a.m. with the director of nursing revealed she: Confirmed the resident had a [DIAGNOSES REDACTED]. Would have expected: -That to have been accurately coded to support that. -The Resident Assessment Instrument manual to have been followed for MDS coding. Review of the (MONTH) (YEAR) Centers for Medicare and Medicaid long-term care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.16, revealed: *Page O-4 related to section O0100J, [MEDICAL TREATMENT], included: -Code peritoneal or [MEDICAL TREATMENT] which occurs at the nursing hom…	2020-09-01
185	185	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	657	E	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure 3 of 24 sampled residents (11, 50, and 235) had a revised and updated care plan to reflect their current needs. Findings include: 1. Interviews and observations on 10/15/19 at 3:00 p.m. and on 10/16/19 at 9:45 a.m. of resident 50 revealed she: Was alert and oriented to person and place. Laid on her bed with no clothes on except a disposable brief. -Showed no discomfort with herself being undressed and surveyors presence. Stated loudly, This place sucks and went on to say how unhappy she was at the facility. -Felt like she was just put in the facility to die, and all the staff cared about was getting her money. -Did not care how she got out of there, but thought it would take dying to get out. -Did not go to any activities and emphatically stated did not care to go. -Did not know who the social worker was or that she had a social worker to visit with. -Had a computer she thought she should bring into her room but did not know where it was. -Went to the dining room for breakfast and lunch but not supper. --Did not visit with any peers and was unhappy with the other residents in the dining room. Interview on 10/17/19 at 7:48 a.m. with certified medication aide D regarding resident 50 revealed she: Did not like to get dressed, and laid in bed without any clothes on. Got upset about being here and cried. Could get upset about little things like just wanting to get a can of pop. She was not always cooperative with her bath. She had never seen any visitors. Review of resident 50's social services notes revealed: 6/25/19: She scored a 6/27 on the pHQ9 (an assessment of depression) indicating depression concerns at this time. She expressed that she feels this is as she has no control of her situation and has no one as intelligent that she is able to interact with her. 7/2/19: Care conference summary: -Resident had refused to participate in the ca…	2020-09-01
186	186	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	658	G	1	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure that professional standards were followed for: One of one closed sampled resident (380) who had been identified with a significant change in condition. One of one sampled resident (38) who had ongoing assessment and treatment for [REDACTED]. Findings include: 1. Review of the medical record for resident 380 revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status (BIMS) assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: An effective date of 7/25/19. Problems/Strengths: At risk for falls related to balance problems during transfers. Goals: -No falls. -Will be free from injury related to fall. Interventions: -Will receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach, with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose and a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical…	2020-09-01
187	187	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	679	D	0	1	SJ6G11	Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (50) who was socially isolated received an individualized activity program based on her interests and needs. Findings include: 1. Interviews and observations on 10/15/19 at 3:00 p.m. and on 10/16/19 at 9:45 a.m. of resident 50 revealed she: Was alert and oriented to person and place. Stated loudly, This place sucks and went on to say how unhappy she was there. -Felt like she was just put there to die, and all the staff cared about was getting her money. -Did not go to any activities and emphatically did not care to go. -Had a computer that she thought she should bring into her room but did not know where it was. -Went to the dining room for breakfast and lunch, but not supper. --Had not visited with any peers and was unhappy with the other residents in the dining room. Review of resident 50's 6/24/19 initial Minimum Data Set (MDS) assessment revealed she: Was cognitively intact. Felt down and depressed. Was tired and had little energy. Had important preferences for the following activities: -Having things to read. -Music. -Animals. -Religion. Going to group activities was not at all important. Review of resident 50's 6/26/19 care plan revealed: Problem/Strengths: She had signs and symptoms of depression. Interventions: -Monitor for signs of depression. -Involve in activities daily. -Social services and activities: in room visits for social stimulation if resident could not attend activities. Interview on 10/17/19 at 7:20 a.m. with activity assistant H regarding resident 50 revealed: She was new to her position having only been there three weeks. -The activity director was gone for ten days. The resident had not come to any activities. -If you tried to encourage her she had a melt down and started crying saying its too much. They did one-to-one (1:1) activities with her mainly by just stopping into visit with her. -She tried to visit at least five minutes, but then she became par…	2020-09-01
188	188	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	684	G	1	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on record review, job description review, interview, and policy review, the provider failed to ensure one of one closed sampled resident (380) received appropriate care and services following an unwitnessed fall. Findings include: 1. Review of resident 380's closed medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the information face sheet for resident 380 revealed the preferred hospital line had been left blank. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: An effective date of 7/25/19. Problems/Strengths: At risk for falls related to balance problems during transfers. Goals: -No falls. -Will be free from injury related to fall. Interventions: -Will receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach, with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and there was a skin tear on his left elbow. -Resident was partially assessed by the nurse while he was on the floor. -He was unable to follow commands. -The on-call medical provider was conta…	2020-09-01
189	189	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	686	G	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (74 and 235) who were at risk for developing pressure ulcers had ongoing assessments and implemented individualized interventions in place to prevent skin breakdown. Findings include: 1. Review of resident 235's medical record revealed: An admission date of [DATE]. [DIAGNOSES REDACTED]. He had orders for a diabetic renal diet. Review of the 9/25/19 admission Minimum Data Set (MDS) assessment for resident 235 revealed: He was able to understand what others said and make himself understood. The Brief Interview for Mental Status assessment score was thirteen indicating he was cognitive. He required: -Extensive assistance of one staff person for dressing and toilet use. -Limited assistance of one staff person for bed mobility, transfer, ambulation, and personal hygiene. He had limited range of motion to his lower extremity. He used a walker or wheelchair. Nutritional approaches had not been coded indicating he required a therapeutic diet. He was at risk for developing pressure ulcers or injuries. He had one stage two pressure ulcer. He was coded as having: -A pressure device for the chair and bed. -Pressure ulcer/injury care. The Care Area Assessment Summary was coded for pressure ulcer area triggered and care planning decision. Review of the Braden Scale for Predicting Pressure Sore Risk from 9/18/19 through 10/8/19 for resident 235 revealed a score of fifteen. -A score of twelve or less represented a high risk. Observation and interview on 10/15/19 at 4:21 p.m. with resident 235 in his room revealed: He was in the facility, because he had broken his left leg a few weeks ago. He had been receiving physical therapy. He had been laying on the bed, had his shoes on both feet, and his heels were not off-loaded. *There was a Prevalon boot laying on the floor. Observation on 10/15/19 at 6:00 p.m. in the[NAME]Win…	2020-09-01
190	190	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	698	D	0	1	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow professional standards for the daily monitoring of one of two sampled residents' (58) [MEDICAL TREATMENT] shunt per the facility policy. Findings include: 1. Observation and interview on 10/16/19 at 10:24 a.m. with resident 58 revealed she: Had been in her room resting in the recliner. Was alert, oriented, and capable of making her needs known. Stated: -I just got back from [MEDICAL TREATMENT] so I'm resting a bit. -I go every Monday, Wednesday, and Friday. Had a shunt for [MEDICAL TREATMENT] placed in her upper left arm. Review of resident 58's medical record revealed: She was admitted on [DATE]. Her primary admission [DIAGNOSES REDACTED]. She had required [MEDICAL TREATMENT] services for her [MEDICAL CONDITION] three times a week. Interview on 10/16/19 at 10:31 a.m. with registered nurse (RN) R regarding resident 58 revealed he: Confirmed the resident went for [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Would have assessed her shunt site on the days she went out for [MEDICAL TREATMENT]. He would not have assessed the resident or her shunt site on any other days for: -A thrill/bruit. -Pain and discomfort. -Hydration and fluid balance was adequate. -Signs and symptoms of infection. -Bleeding, signs of [MEDICAL CONDITION], and [MEDICAL CONDITION]. -A change in her mental condition. -High blood pressure, fatigue, and dry or itchy skin. -A change in her urinary pattern. Review of resident 58's 10/1/19 through 10/31/19 treatment assessment record (TAR) revealed no documentation to support the nursing staff had been assessing her shunt site at all. Review of resident 58's 10/8/19 physician's orders [REDACTED]. Review of resident 58's [MEDICAL TREATMENT] information and assessment forms from 10/1/19 through 10/17/19 confirmed the nursing staff would: *Have only assessed her shunt site on the days she had received [MEDICAL TREATMEN…	2020-09-01
191	191	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	726	G	1	0	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on interview, record review, personnel record review, job description review, and policy review, the provider failed to ensure one of two licensed nurses (K) was competent in recognizing the signs and symptoms of a significant change in condition for one of one closed sampled resident (380). Findings include: 1. Review of resident 380's closed medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and he had a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider was asked to see him while in the building on rounds. -An order was received from his primary care provider to send him to (hospital name) emergency department for evaluation. -The non-emergency number was contacted, and the resident left the faciity on a stretcher. Review of the Neuro (neurological) flow sheet for resident 380 revealed: *The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then…	2020-09-01
192	192	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	740	G	0	1	SJ6G11	Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure one of one sampled resident (50) who was socially withdrawn and unhappy with her placement in the facility received any social services or behavioral health services. Findings include: 1. Interviews and observations on 10/15/19 at 3:00 p.m. and on 10/16/19 at 9:45 a.m. of resident 50 revealed she: Was alert and oriented to person and place. Laid on her bed with no clothes on except a disposable brief. -Showed no discomfort with how she was dressed in the surveyors presence. Stated loudly, This place sucks and went on to say how unhappy she was there. -Felt like she was just put in the facility to die, and all the staff cared about was getting her money. -Did not care how she got out of this place, but she thought it would take dying to get out. -Did not go to any activities and emphatically stated she did not care to go. -Did not know who the social worker was or that she had a social worker to visit with. -Had a computer she thought she should bring into her room but did not know where it was. -Went to the dining room for breakfast and lunch but not supper. --Did not visit with any peers and was unhappy with the other residents in the dining room. Review of resident 50's 9/10/19 Minimum Data Set (MDS) assessment revealed she: Was cognitively intact. Felt down and depressed. Was tired and had little energy. Interview on 10/16/19 at 10:16 a.m. with certified nursing assistant C regarding resident 50 revealed she had: Known her from the previous nursing home she was at. -A history of failure to thrive. Interview on 10/17/19 at 7:48 a.m. with certified medication aide D regarding resident 50 revealed she: Did not like to get dressed, and laid in bed without any clothes on. Got upset about being here and cried. Could get upset about wanting to get a can of pop. She was not always cooperative with her bath. She had never seen any visitors. Review of resident 50's social services notes re…	2020-09-01
193	193	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	803	E	0	1	SJ6G11	Based on observation and interview, the provider failed to ensure seven of eight randomly observed residents in[NAME]Wing dining room received the appropriate amount of protein during the evening meal by one of one observed dietary cook (O). Findings include: 1. Observation and interview on 10/15/19 from 5:40 p.m. through 5:55 p.m. with dietary cook O during the evening meal service in the[NAME]Wing dining room revealed: He began to serve the evening meal at 5:45 p.m. While serving out the meat mixture he would alternate between putting two or three scoops of the meat mixture on the buns. Of the eight randomly observed residents seven residents received two scoops of the meat mixture on their bun. One resident had received three scoops of the meat mixture on the bun. Interview and observation on 10/15/19 at 5:55 p.m. with dietary cook O and review of the scoop sizes he used during the evening meal revealed: The scoop used for the meat mixture had the number 40 on it. He had given the residents two scoops of the meat mixture. They usually used a blue scoop, but there was not one. Interview on 10/15/19 at 6:10 p.m. with dietary manager B regarding the above observed evening meal revealed: They had broken a lot of the scoops. She had checked the menu on[NAME]Wing, and the residents were to have received three ounces of the meat mixture. She had checked the scoop size and confirmed it had been a one ounce scoop. -The residents would have needed to receive three scoops to get the full three ounce portion. The dietary cook had not used the correct scoop. Interview on 10/17/19 at 8:30 a.m. with the administrator regarding the evening meal on 10/15/19 in the[NAME]Wing revealed: Each kitchenette had a copy of the scoop sizes. Her expectations would have been for the dietary cook to have used the correct scoop size. If a certain scoop was broken she would have expected the staff to know how to use a correct scoop to get the correct portion size. *They were in the process of purchasing new kitchen supplies. Re…	2020-09-01
194	194	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	842	D	1	0	SJ6G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on closed record review, interview, job description review, and policy review, the provider failed to have complete documentation for one of one closed sample resident (380). Findings include: 1. Review of the medical record for resident 380 revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED]. The 7/22/19 admission Minimum Data Set assessment showed: -A Brief Interview of Mental Status score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. He had sustained a fall without injury on 8/30/19. Review of the information face sheet for resident 380 revealed the preferred hospital line had been left blank. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: An effective date of 7/25/19. Problems/Strengths: At risk for falls related to balance problems during transfers. Goals: -No falls. -Would be free from injury related to fall. Interventions: -Would receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and he had a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was transferred to his bed for a full assessment.…	2020-09-01
195	195	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	867	G	0	1	SJ6G11	Based on observation, record review, interview, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to residents' care within the facility. Findings include: 1. Interview on 10/17/19 at 2:59 p.m. with the administrator regarding their QAPI program revealed: She was the QAPI coordinator. They would like to do monthly meetings but had been meeting quarterly. -They were due for their next quarterly meeting in October. They currently had a medical director. -They were in the process of finding a new medical director. Their last QAPI meeting was in (MONTH) or July. The medical director had not attended all of the quarterly meetings. -They would email information to the medical director if they were unable to attend. They used the Casper report for their QAPI meetings. Each department reported on what they had been working on. The pharmacist had attended the quarterly QAPI meetings. They were not working on any performance improvement plans (PIPS). -They knew they had issues. -They had not had the resources or staff to initiate PIPS or to follow through on the PIPS. Review of the QAPI Sign-In Sheet from (MONTH) 11, (YEAR) through (MONTH) 26, 2019 revealed the medical director had attended the QAPI meetings in (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019. Review of the provider's 2019 QAPI Plan revealed: Purpose: -To promote the highest quality of life for our residents while providing quality care. The QAPI plan included policies and procedures used to:-Identify and use data to monitor our performance. -Establish goals and thresholds for our performance measurements. -Utilize resident, staff and family input. -Systematically analyze underlying causes of systemic problems and adverse events. -Develop corrective action or performance improvement activities. (Facility name) will conduct Performance Improvement Projects that are designed to take a systematic approa…	2020-09-01
196	196	AVANTARA NORTON	435039	3600 SOUTH NORTON AVENUE	SIOUX FALLS	SD	57105	2019-10-17	880	E	0	1	SJ6G11	Based on observation, interview, record review, policy review, and manufacturer's recommendations review, the provider failed to ensure appropriate infection control practices and protocols were followed for: Glove use and hand hygiene during: -Residents' personal care -Cleaning of residents' rooms. Cleaning and disinfecting of two of two residents (2 and 73) glucometers by one of one observed licensed nurse (R). Two of two sampled residents (74 and 235) observed dressing changes by one of one observed licensed nurse (R). Maintaining a sanitary environment for: -One of one storage room that had resident use items stored inside of it. -One of three medication rooms (east wing) that was not clean. -Two of two observed tub rooms (central and east). -One of one resident (38) observed dressing change with one of one registered nurse (RN) I. Findings include: 1. Observation on 10/16/19 from 11:15 a.m. through 11:30 a.m. with registered nurse (RN) R during observations of residents' blood sugar checks revealed: At 11:20 a.m.: -He gathered the supplies and went to resident 73's room. -She was not in her room. -He went to the therapy room where she was, and he checked her blood sugar. -Returned to the medication cart, took out a Chlorox wipe, wiped the glucometer off, and left it to air dry. At 11:30 a.m.: -He gathered the supplies and checked resident 2's blood sugar. -Returned to the medication cart, took out a Chlorox wipe, wiped the glucometer off, and left it to air dry. Interview at the above time with RN R regarding the cleaning of the glucometers revealed: Each resident had their own glucometer with their name on it. Each glucometer was stored separately in the medication cart. *That was his usual practice for cleaning the glucometer off after each use. Review of the provider's 5/3/17 Single Resident Use Glucometers policy revealed: Glucometers will be cleaned per manufacture's guidelines after each use and when quality controls are completed. Review of the Assure Prism Blood Glucose Monitoring System User…	2020-09-01
197	197	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	679	E	0	1	YOJP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure one-on-one activities were provided for three of three sampled residents (8, 23, and 63). Findings include: 1. Review of resident 63's medical record revealed: She had been admitted on [DATE]. Her 1/3/20 admission Minimum Data Set (MDS) assessment revealed her: -Brief Interview for Mental Status (BIMS) assessment score was fifteen indicating her cognition was intact. -[DIAGNOSES REDACTED]. -Activities that were very important to her included: listening to music, being around animals, doing her favorite activities, and going outside. Review of resident 63's 1/2/20 care plan revealed: She would potentially benefit from one-on-one activity programming. She would engage in one-on-one program three to four times a week. Conduct daily motivations rounds to promote increased involvement and response to therapeutic activities. Provide leisure skill education covering the importance of being active and how that positively influences quality of life. Encourage and suggest she try new activities. Review the activity calendar to showcase the various and diverse programs. Assist her in identifying leisure time interests and discuss potential new interests. Observation and interview on 1/29/20 at 10:29 a.m. with resident 63 revealed she: Had been in bed with the lights dimmed. -The TV was on, and a book was on her bedside table. -There were no other activity books such as word search or crossword puzzles in her room. Liked to keep her door closed. Had not remembered any activity staff visiting with her. -Housekeeping staff had visited with her but no other staff. Was very lonely. Had a son and a good friend who visited occasionally. Would have liked some word search books. Review of resident 63's 1/2/20 activity evaluation revealed: She had been admitted for rehabilitation (rehab). *She was confined to her bed most of the…	2020-09-01
198	198	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	689	D	0	1	YOJP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (67) received adequate supervision to prevent falls. Findings include: 1. Review of resident 67's 1/6/20 Minimum Data Set assessment revealed: She had been admitted on [DATE]. She had multiple [DIAGNOSES REDACTED]. Her Brief Interview for Mental Status assessment score had been fifteen indicating her cognition was intact. She had been able to make her needs known. She had required the assistance of two staff members for transfers. She did not walk. She had been on a scheduled pain management plan. Her medication list had included: an [MEDICAL CONDITION] medication, an antidepressant, and an opioid pain medication. Observation and interview on 1/28/20 at 10:30 a.m. with resident 67 revealed: She had fallen in the bathroom on 1/28/20 at 9:15 a.m. -No one had seen her fall. -The certified nursing assistants (CNA) had assisted her to the toilet, and she had fallen when she tried to get up by herself. She would like to have therapy again. She did better with transfers when she had been receiving physical therapy. She would like to be able to walk again. She denied pain and no bruising was noted. She had minimal use of her left arm due to [MEDICAL CONDITION]. Interview on 1/29/20 at 3:20 p.m. with occupational therapist/director of rehabilitation G revealed: The resident had: -Not been on a restorative program. -Approached her and asked her about starting physical therapy again. She had received an e-mail on 1/28/20 late afternoon from registered nurse (RN) H with physician orders [REDACTED]. *The resident had been: -Scheduled to be evaluated on 1/29/20 by the occupational therapist and on 1/30/20 by the physical therapist. -Last referred to physical and occupational therapy on 4/10/19, and she had been discharged from their caseload in (MONTH) 2019. Interview on 1/29/20 at 3:30 p.m. with RN H regarding reside…	2020-09-01
199	199	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	693	D	0	1	YOJP11	Based on observation, interview, and policy review, the provider failed to ensure the correct procedure was followed for verification of placement of a gastrostomy feeding tube for two of four sampled residents (14 and 44) with feeding tubes by two of two licensed practical nurses (LPN) (E) and (F). Findings include: 1. Observation and interview on 1/28/20 at 11:17 a.m. with LPN [NAME] while she prepared and administered resident 14's gastric tube feeding revealed: She did not do hand hygiene when she entered the room. With her bare hands she assembled her supplies on the counter by the sink. She removed the cap from the tube feeding bag, poured in the liquid, and primed the bag. She did not wash her hands but put on gloves. Prior to connecting the tube feeding she attempted to verify the placement of it: -By instilling air into the tube. -Stated she used ten to fifteen milliliters of air directly into the tube to verify placement. -She listened with a stethoscope for that air movement over the resident's stomach and tube insertion areas. -Stated she heard the air movement. She then attempted to verify that tube placement by aspiration. -She used a sixty cubic centimeter syringe to check for residual stomach content without results. Instilled a sixty milliliter water flush. -Proceeded with the tube feeding by connecting the feeding bag to the feeding tube. Stated the above had been her usual procedure for the resident's tube feeding. 2. Observation on 1/28/20 at 9:15 a.m. during administration of resident 44's tube feeding revealed: LPN F failed to verify tube placement before she administered the water flush pre-feeding. She had correctly aspirated before starting the feeding, but had not checked the pH of gastric contents. She had checked placement after she had administered the water and said she had forgotten to do that prior to the water flush. Surveyor: 3. Interview on 1/30/20 at 1:59 p.m. with director of nurses A regarding the above revealed: Her expectation had been for LPN [NAME] to follow t…	2020-09-01
200	200	AVANTARA MOUNTAIN VIEW	435040	916 MOUNTAIN VIEW ROAD	RAPID CITY	SD	57702	2020-01-30	697	D	0	1	YOJP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure accurate and effective pain management had been implemented for one of one sampled resident (8) reviewed for pain management. Findings include: 1. Review of resident 8's medical record revealed: She was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was receiving comfort care, and a hospice consultation had been ordered. Review of resident 8's 11/1/19 Minimum Data Set assessment revealed: Her Brief Interview for Mental Status assessment score was fourteen indicating her cognition was intact. She had experienced occasional pain. Her worst pain had been rated a nine on a pain scale of zero to ten with ten being the worst pain. Review of resident 8's revised 10/29/19 care plan goal revealed: Goal: -Resident will achieve acceptable level of pain control within one hour of medication administration through the next review date. Interventions included: -Assess pain characteristics, assist resident to a position of comfort, advise resident to request pain medication before pain becomes severe, evaluate pain medication effectiveness, monitor for non-verbal cues of pain, use non-pharmacological interventions, and medicate resident as ordered. Review of resident 8's 1/1/20 through 1/29/20 Medication Administration Record [REDACTED] Her scheduled pain medications had included: -[MEDICATION NAME] at 6:00 a.m. daily. -[MEDICATION NAME] gel applied [MEDICATION NAME] at 8:00 a.m. and 5:00 p.m. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 milligram (mg) at 6:00 a.m. and 6:00 p.m. Her as needed (PRN) pain medications had included: -Muscle rub cream to her neck, shoulders, and calf every six hours as needed. --That had not been applied during the above time frame. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, one tablet every four hours. --She had received that medication eight times during the above time frame for pain rated between two and ten. --Four…	2020-09-01

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CREATE TABLE [cms_SD] (
   [facility_name] TEXT,
   [facility_id] INTEGER,
   [address] TEXT,
   [city] TEXT,
   [state] TEXT,
   [zip] INTEGER,
   [inspection_date] TEXT,
   [deficiency_tag] INTEGER,
   [scope_severity] TEXT,
   [complaint] INTEGER,
   [standard] INTEGER,
   [eventid] TEXT,
   [inspection_text] TEXT,
   [filedate] TEXT
);