cms_SD
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5,155 rows
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2018-03-29 | 565 | E | 0 | 1 | XF2S11 | Based on observation and interview the provider failed to ensure: *Meals were served on time for two of two observed meals in the main dining room. *Residents were aware of alternative meal options in one of two dining rooms (main dining room). Findings include: 1. Interview on 3/26/18 at 4:45 p.m. with the administrator revealed the meal times were: *In the rehabilitation (rehab) dining room breakfast was served at 7:30 a.m., lunch at 11:30 a.m., and supper at 5:30 p.m. *In the main dining room breakfast was served at 8:00 a.m., lunch at 12:00 noon, and supper at 6:00 p.m. Surveyor Observation on 3/26/18 from 5:54 p.m. through 6:30 p.m. in the main dining room revealed: *At 6:11 p.m. the serving window was closed. -No meals had been served yet. *At 6:15 p.m. the serving window opened, and the first tray was served. -An unidentified resident refused the tray and asked for soup. --She kept the bread and fruit. -Three out of four of the residents at the same table refused their tray and only took the fruit. Observation and interview on 3/27/18 from 6:13 p.m. through 6:20 p.m. in the main dining room revealed: *At 6:13 p.m. the serving window was opened. -The kitchen had not started serving. *Interview at 6:15 p.m. with licensed practical nurse D regarding resident choices for meals revealed: -They did not ask the residents prior to the meal as to what they would like to eat. -He stated We tried that once and it didn't work. -He said A resident would order fish for supper and then once supper came they would be like I don't want fish, and the server would say Yes you ordered this at breakfast today, and the resident would be like, No I don't want it, I want something else. -He thought it worked better now. --They just took the tray with the main menu meal option and if they did not want it they offered the alternative. *At 6:19 p.m. the serving window opened. *At 6:20 p.m. the first tray was served. Interview with a resident representative revealed: *Supper is routinely not served until 6:20 p.m. or 6:30 p.m. -Suppe… | 2020-09-01 |
| 2 | 2 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2018-03-29 | 657 | D | 0 | 1 | XF2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to update and revise care plans for 3 of 18 sampled residents (8, 28, and 60). Findings include: 1. Review of resident 60's medical record revealed she had developed a pressure ulcer to her left heel on 3/12/18. Her care plan had not been updated to reflect that information. Refer to F686, finding 1. 2. Review of resident 8's 12/5/17, 2/14/18, and 3/16/18 care plans for skin integrity and pressure ulcers revealed a gap in documentation with no preventative interventions for a resident with a history of pressure ulcers. Refer to F686, finding 2. 3. Review of resident 28's undated care plan revealed she: *Was admitted on [DATE]. *Had two hospitalization s, and her last readmitted was 1/31/18. *Had focus areas for: [MEDICAL CONDITION], anticoagulant therapy, insulin r/t (related to) diabetes, diuretic therapy r/t heart failure, and respiratory distress. *Interventions and tasks such as: -Labs as ordered. -Monitor blood sugar, lab results as ordered by physician. -Administer medication pre physician orders. --Interventions and tasks were not resident specific. --Did not have adequate information to provide interventions and methods to monitor above areas. 4. Interview on 3/29/18 at 7:50 a.m. with the minimum data set (MDS) nurse regarding care plans revealed: *The initial care plan was created from the nurses admission assessment. *The first of the year they had started a new process with the care plans where if a resident was admitted and then discharged upon return to the facility, the care plan had to be completely regenerated. -Previous to the first of the year the care plan could be used from before. *The nurses were not comparing the previous care plan to the current care plan. -Interventions and tasks had not been brought forward. -Care plans were not complete. *She stated resident 25's care plan would be corrected today. *She had been reviewing them upo… | 2020-09-01 |
| 3 | 3 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2018-03-29 | 686 | E | 0 | 1 | XF2S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and guideline review, the provider failed to ensure interventions were in place for two of three sampled residents (8 and 60) who developed pressure ulcers. Findings include: 1. Interview on 3/27/18 at 2:11 p.m. with licensed practical nurse (LPN) [NAME] and the administrator regarding the list of residents with pressure areas revealed: *Three out of the seven residents had suspected deep tissue injuries (SDTI). -If the area was deep purple or the blister was blood filled, it would indicate it was a deep tissue injury. *The Braden Risk Assessment tools were completed on the computer. *The Pressure Ulcer Scale for Healing (PUSH) tool was completed on paper. *The registered nurses staged the skin areas. *They had identified resident 60's left heel had a SDTI due to the blister being filled with blood. Observation and interview on 3/27/18 at 2:38 p.m. with LPN D and the director of nursing (DON) revealed: *They were completing a dressing change to resident 60's left heel. *The resident was sitting in her wheelchair. *She had a wound vac on the outer side of her left foot. -They were not to do anything with that at that time, as she had just returned from an appointment for it. *The orders were for a foam dressing and [MEDICATION NAME]. *She had a heel protector on her left foot. *The SDTI was approximately the size of a quarter. -It was unopened but dark purple and black in color. *It had developed while she had been a resident in the facility. Observation on 3/27/18 at 4:15 p.m. of resident 60 revealed she was in her room visiting with a visitor. She was sitting up in her wheelchair. Observation on 3/27/18 at 5:14 p.m. of resident 60 revealed she was propelling herself in her wheelchair going to the dining room. Observation on 3/28/18 at 8:39 a.m. of resident 60 revealed she was in therapy. Review of resident 60's medical record revealed: *Her admitted had been 1/17/18. *Her [DIAGNOSES REDACTED].>… | 2020-09-01 |
| 4 | 4 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2017-05-17 | 281 | D | 0 | 1 | V34811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure one of four sampled residents (4) who was an insulin dependent diabetic received her medications as ordered by the physician. Findings include: 1. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 4's physician's orders [REDACTED]. *[MEDICATION NAME] 3 units (u) every morning (q. a.m.). *Humalog insulin: -7 units before breakfast. -4 units before lunch. -2 units before supper. *In addition she received additional Humalog insulin on a sliding scale based on a her blood sugars: -201-250: 1 unit. -251-300: 2 units. -301-350: 3 units. -351 or greater: 4 units. *The physician was to be notified if her blood sugars were lower than 60 or higher than 450. Review of resident 4's physician's orders [REDACTED]. Review of resident 4's medical record revealed a 5/15/17 fax had been sent to her physician stating Please note that pt (patient) scheduled Humalog was missed over the weekend. Attached to that fax was a copy of her blood sugars. Interview on 5/16/17 at 10:00 a.m. with registered nurse/unit manager A regarding resident 4 revealed: *On 4/11/17 the resident's Humalog insulin for the noon meal had been changed from 3 to 4 units. *The nurse had yellowed out on the treatment record/medication record the 3 units that meant it had been discontinued. *On the next frame of the medication record she wrote the medication change increasing the noon dosage to 4 units. *She also yellowed out from 5/11/17 noon dose through 5/31/17, 5/11/17 through 5/31/17 for the supper dose, and 5/12/17 through 5/31/17 for the breakfast doses. -When a medication had been yellowed out that meant that order had been discontinued. *She never re-wrote those orders for breakfast or supper, so none of those doses were given. *The resident had missed her insulin for seven meals. *The error was found on 5/15/17 and immediatel… | 2020-09-01 |
| 5 | 5 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2019-06-26 | 561 | D | 0 | 1 | 9U2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and admission packet review, the provider failed to ensure one of one sampled resident's (52) choices related to her therapy schedule had been followed. Findings include: 1. Review of resident 52's medical record revealed: *She had been admitted on [DATE]. *She was alert and oriented. *Her 5/14/19 admission Minimum Data Set assessment regarding her daily preferences revealed: -It was very important for her to choose her own bedtime. --There was no question to specifically address how important her wake-up time would have been. *Her 6/26/19 care plan revealed: -Involve (resident name) in IDT (interdisciplinary team) and care planning. -Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe. Observation and interview on 6/24/19 at 4:56 p.m. with resident 52 in her room revealed: *She was sitting in her bed reading a book.*She had been admitted about five weeks ago following a fall at home when she broke her hip. *She was working with therapy services and hoping to get back home soon. *Her only complaint was having to get up so early in the morning for therapy sessions. *She was not a morning person and did not feel well at that time of the day. -She further stated she used to have low blood pressure issues early in the morning. *The white dry erase board in her room indicated she would have three therapy appointments the next day at the following times: -At 6:30 a.m. with occupational therapy (OT). -At 8:30 a.m. with physical therapy (PT). -At 12:00 noon with speech therapy (ST). *She had told more than one therapy staff person that she did not like those early morning appointments, and they still scheduled her that way at times. Observation and interview on 6/25/19 at 9:05 a.m. with resident 52 in her room revealed:*She had just returned from therapy and was sitting in her wheelchair. *She had slept well the night before, and th… | 2020-09-01 |
| 6 | 6 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2019-06-26 | 610 | D | 0 | 1 | 9U2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on interview, record review, and policy review, the provider failed to thoroughly investigate an incident for one of one sampled resident (47) who had a fall with a head injury. Findings include: 1. Review of resident 47's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was an eleven indicating her cognition was moderately impaired. *She required the extensive assistance of two staff members for bed mobility. *On 5/5/19 she had rolled out of bed. Review of resident 47's fall investigation from 5/5/19 revealed: *She fell out of bed. *Positioning pillows were discontinued on 12/26/19 due to limited mobility. *The staff that were present had been interviewed. -She had been provided incontinent care at 3:00 a.m. -They had been in her room at 4:00 a.m. -She was found on the floor at 4:15 a.m. --Her bed was damp, and she was wet with urine. *The investigation did not indicate the resident's position in the bed fifteen minutes prior to the fall. Interview on 6/26/19 at 8:28 a.m. with the director of nursing (DON) revealed she felt if a resident was asked immediately following an incident regardless of their BIMS score they could tell you what happened. Interview on 6/26/19 at 8:33 a.m. with registered nurse E, the director of nursing, and the administrator regarding resident 47's 5/5/19 fall revealed: *She was taken at her word for how she fell out of bed. *It was not investigated how the resident was positioned in her bed prior to the fall. -If she had been near the edge of the bed when staff were in the room fifteen minutes prior to the fall it was the expectation she would have been repositioned. -They agreed what the resident was doing prior to a fall could be added to their investigation form. *There were no other interventions evaluated prior to the implementation of the positioning pillows. *They did not know what had caused the fall. Review of the provider's… | 2020-09-01 |
| 7 | 7 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2019-06-26 | 679 | D | 0 | 1 | 9U2F11 | **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 residents (47) had individualized and meaningful activities offered and documented. Findings include: 1. Review of resident 47's 12/14/18 annual Minimum Data Set assessment revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was an eleven, indicating her cognition was moderately impaired. *She nor her family could be interviewed regarding her preferences. *The staff assessment of preferences was completed and revealed her preferences were: -Reading books or magazines. -Listening to music. -Being around animals. -Doing things in groups. -Participating in her favorite activities. -Spending time outdoors. Interview with resident 47 on 6/24/19 at 4:13 p.m. revealed: *She laid in her bed and watched TV during the day. *She liked to go to BINGO. Observations of resident 47 on 6/24/19 from 4:10 p.m through 7:15 p.m., on 6/25/19 from 7:30 a.m. through 6:45 p.m., and on 6/26/19 from 7:30 a.m. through 3:00 p.m. revealed: *She was in her room in her bed. *She was in her room in her wheelchair. -Her TV was on at times. *She went to the dining room for meals. Review of resident 47's 6/25/19 care plan revealed: *She was receptive to: -Music. -Special events. -BINGO. -Manicures. -Visiting with staff. -Volunteers. -Pet visits. -Watching TV, specifically channel 25. Review of resident 47's activity logs revealed: *In (MONTH) 2019 she was not offered activities eleven of thirty days. -On four other days she was only offered the leisure cart and refused it. *In (MONTH) 2019 she was not offered activities on eight of thirty-one days. -On five other days she was only offered the leisure cart and refused it. *In (MONTH) 2019 she had not been offered activities twelve out of twenty-five days. -On six other days she had only been offered leisure cart and refused it. Interview on 6/26/19 at 9:14 a.m. with the a… | 2020-09-01 |
| 8 | 8 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2019-06-26 | 744 | D | 0 | 1 | 9U2F11 | **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 four sampled residents (69) who had dementia and behaviors had received appropriate interventions and documentation to support her psychosocial well-being. Findings include: 1. Review of resident 69's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was a ten indicating her cognition was moderately impaired. *Her [DIAGNOSES REDACTED].>-Shortness of breath. -[MEDICAL CONDITION]. -Major [MEDICAL CONDITION] recurrent. -Anxiety disorder unspecified. -Dementia in other disease classified elsewhere with behavioral disturbance. Review of resident 69's nursing progress notes from (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 revealed: *In (MONTH) (YEAR) she had eighteen of thirty-one days where yelling out behaviors were documented. -Of those eighteen days seven days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 eighteen of thirty-one days there were yelling behaviors documented. -Of those eighteen days two days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 she had one of twenty-five days with documentation of yelling out behaviors. -On that day a non-pharmalogical intervention was used and was successful. Review of resident 69's 6/26/19 care plan revealed: *Seven of eleven interventions for anxiety were implemented on 2/26/19. *Interventions included: -Administer medication per physician orders [REDACTED]. Try non-pharmacological interventions on her; offer the bathroom, offer something to eat and drink, monitor her health status/pain, try and redirect her to an activity in her room or in a group setting. She does like to watch TV sometimes. -Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs PRN. -Identify and decrease environmental stressors. --Initiated 6/13/18… | 2020-09-01 |
| 9 | 9 | PRAIRIE HEIGHTS HEALTHCARE | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2019-06-26 | 758 | D | 0 | 1 | 9U2F11 | **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 four sampled residents (69) had appropriate documentation to support the rationale for adding and increasing [MEDICAL CONDITION] medications. Findings include: 1. Review of resident 69's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was a ten indicating her cognition was moderately impaired. *Her [DIAGNOSES REDACTED].>-Shortness of breath. -[MEDICAL CONDITION]. -Major [MEDICAL CONDITION] recurrent. -Anxiety disorder unspecified. -Dementia in other disease classified elsewhere with behavioral disturbance. Observation and interview on 6/24/19 at 4:40 p.m. with resident 69 revealed: *She liked the facility. *The staff were nice to her. *She did not display any signs or symptoms of anxiety during the interview. Random observations of resident 69 on 6/25/19 from 7:30 a.m. through 6:45 p.m. and on 6/26/19 from 7:30 a.m. through 4:00 p.m. revealed: *She was sitting in her room in her wheelchair. *Visitors were playing cards with her at times. *Her essential oil diffuser was on at times. *No yelling out was noted. Review of all of resident 69's nursing progress notes from (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 revealed: *In (MONTH) (YEAR) she had eighteen of thirty-one days where yelling out behaviors were documented. -Of those eighteen days seven days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 eighteen of thirty-one days there were yelling behaviors documented. -Of those eighteen days two days indicated a non-pharmalogical intervention was attempted. *In (MONTH) 2019 she had one of twenty-five days with documentation of yelling out behaviors. -On that day a non-pharmalogical intervention was used and was successful. Review of resident 69's medication administration records revealed: *On 12/26/19 [MEDICATION NAME] 2.5 milligrams (mg) was added at… | 2020-09-01 |
| 10 | 10 | AVANTARA MILBANK | 435009 | 1103 SOUTH SECOND STREET | MILBANK | SD | 57252 | 2018-10-03 | 584 | D | 0 | 1 | LZ7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the provider failed to ensure the heater units that circulated hot water in five of eight resident rooms (401, 403, 405, 406, and 408) on one of five resident halls (400) had missing front heat shields. Findings include: 1. Observation during the survey on 10/1/18 from 4: 00 p.m. through 4:30 p.m., 10/2/18 from 1:00 p.m. through 3:00 p.m., and 10/3/18 at 4:00 p.m. revealed: *Resident rooms 401, 403, 405, 406, and 408 heater units had damage to them including: -The front heat shields had exposed sharp heating fins. -The front heat shields were not attached and had exposed sharp connectors. -Half of the front heat shield was missing from room [ROOM NUMBER]'s heater and his comforter had fallen onto the heating fins. Interview on 10/3/18 at 6:00 p.m. with the administrator revealed she was not aware of the heater units disrepair. She agreed those units could have caused injury to residents. She was not aware of any policy or preventative maintenance schedule that was completed for each room. She had just initiated a system for reporting items to be fixed to maintenance. | 2020-09-01 |
| 11 | 11 | AVANTARA MILBANK | 435009 | 1103 SOUTH SECOND STREET | MILBANK | SD | 57252 | 2018-10-03 | 609 | D | 0 | 1 | LZ7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on observation, interview, record review, and policy review, the provider failed to ensure investigations had been completed for 3 of 3 incidents for 1 of 14 sampled residents (37) for potential verbal, mental, and physical abuse. Findings include: 1a. Observation and interview on 10/2/18 at 3:00 p.m. with resident 37 shared her concerns including the following: *She stated the staff reminds me of one big [NAME]s and she does not need that in her life. *She did not want those people in her life, and when she asked to have other staff assist her she was told she had to accept whoever was assigned. *She stated staff did not answer her call light for hours and sometimes not at all. *She was seated on her bed with a tray table in front of her. *Her wheelchair was located across the room and pushed under the sink. *She was unable to use her right hand due to a previous stroke. *At 3:16 p.m. she pressed her call light. *At 3:22 p.m. this surveyor went into the hall to ensure the light had been activated and the light was on. *At 3:35 p.m. an unidentified male staff person came into the room and told her he would get someone else to assist her. *At 3:38 p.m. the director of nursing (DON) entered the room, stated she did not usually help her but would do her best, and used the standing lift to assist her to the commode. Review of resident 37's medical record revealed: b. On 06/23/18 at 1:33 p.m. a progress note by the DON revealed the resident had told staff she had blisters on her left hand. The DON had documented: -Firm blisters on the knuckles of the left thumb, index, 3rd and 4th fingers. Thumb being the largest. Skin on the back of hands is very ruddy and red. *On 06/25/18 an incident follow-up notation completed by the DON revealed: -Discussed by (interdisciplinary team), resident is known to run hot water for long periods of time, up to 2-4 hours to wash her hair and this is what she has been doing. No amount of verbal counseli… | 2020-09-01 |
| 12 | 12 | AVANTARA MILBANK | 435009 | 1103 SOUTH SECOND STREET | MILBANK | SD | 57252 | 2019-11-06 | 584 | E | 0 | 1 | O5MT11 | Based on observation, interview, and policy review, the provider failed to ensure a sanitary and homelike environment was maintained for: *One of one randomly observed laundry service area was clean and in good condition. *The heating system in one of one laundry service area was working properly to ensure the temperature in the room was maintained at a comfortable working level. *The ceiling tile on four of four observed wings (100, 300, 400, and 500) was clean and in good repair. *Multiple metal brackets and hardware holding the ceiling tile in place for four of four observed wings (100, 300, 400, and 500) had cleanable surfaces. Findings include: 1a. Observation and interview on 11/5/19 at 9:30 a.m. with laundry assistant A of the laundry service area revealed: *The flooring in the entire area was tiled. -Multiple tiles throughout the area were chipped or had broken pieces off of them. Those missing and chipped pieces of tile: --Were rough and jagged around the edges of it. --Created and exposed a concrete surface that was uncleanable. *The entire wall located by the two clothes dryers and resident clean clothes storage area was warped, chipped, and missing large areas of paint. -Those areas covered greater than 50% (percent) of the wall. -Those areas had exposed the wall board and gypsum underneath of it to create an uncleanable surface. *There were four wooden doors in that area. -The protective covering on those doors was gouged, chipped, or missing in several areas. --Those areas exposed the raw wood underneath of it and created an uncleanable surface. *There were two clothes dryers in the clean clothes area. The protective covering on the outside surfaces of one of those dryers was missing and was rusted underneath of it. -Those rusted areas created an uncleanable surface. *There were two small metal clothes carts in the clothes drying area. She used the carts to transport the clean linens from the washer to the dryers. -Those carts: --Were on wheels and had the capability of being rolled to other areas o… | 2020-09-01 |
| 13 | 13 | AVANTARA MILBANK | 435009 | 1103 SOUTH SECOND STREET | MILBANK | SD | 57252 | 2019-11-06 | 684 | D | 0 | 1 | O5MT11 | **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 to ensure physician notification, ongoing skin assessments, and treatments had occurred for one of one sampled resident (45) who had a change in the condition of her skin. Findings include: 1. Observation on 11/4/19 at 2:11 p.m. of resident 45 revealed: *The resident's door to her room had been partially shut. *Upon knocking on the door there was no answer. *The room was darkened with her window curtains partially opened and the television on. *She: -Was laying in her bed resting on her left side and facing the wall. -Had an air mattress on her bed to ensure pressure relief occurred -Was dressed in a bedtime hospital type gown. -She opened her eyes and made eye contact when spoken to but made no attempt to respond. -Was not observed making any spontaneous body movements. Interview on 11/4/19 at 2:29 p.m. with licensed practical nurse (LPN) G regarding resident 45 revealed: *The resident was recently placed on bedrest. *She stated: -It hurts her too much to transfer her with the lift. -She's comfort care. Observation on 11/4/19 at 4:30 p.m. of resident 45 revealed the same as observed above at 2:11 p.m. Observation and interview on 11/4/19 at 4:34 p.m. with certified nursing assistants (CNA) C and D with resident 45 revealed: *They had prepared to assist the resident with repositioning and personal care. *The resident had: -Been incontinent of both urine and bowel movement (BM). -Been in the same position as observed above at 2:11 p.m. -Required the CNAs to assist her with positioning, incontinence care, and dressing. *When she had been turned onto her right side there was a large circular reddened area on her left buttock. -That area was approximately 12 centimeters (cm) by (x) 7 cm in size and was the color of a red apple. -The entire edge of the wound was a deeper red and approximately 0.25 cm in width. -The entire surface… | 2020-09-01 |
| 14 | 14 | AVANTARA MILBANK | 435009 | 1103 SOUTH SECOND STREET | MILBANK | SD | 57252 | 2019-11-06 | 880 | E | 0 | 1 | O5MT11 | Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions had been maintained during personal care for three of five sampled residents (15, 20, and 45) by three of three observed certified nursing assistants (CNA) C, D, and E. Findings include: 1a. Observation on 11/4/19 at 3:36 p.m. with CNAs C and D with resident 20 revealed: *The resident had been sitting on the edge of her bed sorting her mail. *She had been incontinent of bowel movement (BM). -Her BM was so large it had run out of the incontinent brief and down her right thigh. *She had required the use of a mechanical stand-aide for transfers. *The CNAs prepared to assist the resident with personal care and a transfer from her bed onto a bedside commode. *Without washing or sanitizing their hands upon entering the room they put on a clean pair of gloves. *With those gloves on CNA D: -Moved the stand-aide closer to the resident. -Removed the blanket off the resident's lap. -Touched the handle on the water faucet and turned the water on. -Got a package full of dry wipes, opened that package, and wet the dry wipes. -Touched the handle on the water faucet and turned the water off. -Took the wet wipes and started to clean the BM off of her thigh. -Removed her gloves and without sanitizing or washing her hands put on another pair of gloves. *With those gloves on CNA D: -Assisted CNA C with using the stand-aide to stand the resident up. -Removed the resident's incontinent brief and took several of the wet wipes and cleaned BM off her bottom. *With those soiled gloves on she took more wet wipes and cleaned the resident's front perineal area. --The CNA cleaned her front area by wiping from the back towards the front of her perineal area. --There had been BM on several of those wet wipes. *Both of the CNAs removed their gloves and assisted the resident to sit down on the bedside commode. *They washed their hands prior to leaving the room to offer the resident privacy and wait for the bath-aide to assist them further. -That … | 2020-09-01 |
| 15 | 15 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2018-02-07 | 609 | E | 0 | 1 | TWBV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure: *Four of four unwitnessed falls with injury had been reported to the South Dakota Department of Health (SD DOH) in a timely manner for two of two sampled residents (17 and 62). *Thorough investigations had been completed for three of three falls for one of one sampled resident (62) who had cognitive impairment. Findings include: 1a. Review of resident 62's medical record revealed: *She had been admitted on [DATE]. *She had fallen on 11/21/17, 12/9/17, and 12/17/17. Review of resident 62's 1/2/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was six indicating her cognition was severely impaired. *She had two or more falls with injury during that assessment period. b. Review of resident 62's 11/21/17 internal fall report revealed: *She had fallen at 5:05 p.m. in her room. *Staff heard her calling for help from her room. *Upon entry she was found lying on her back with her head towards the doorway. *The walker had been laying across her abdomen. *She stated she was throwing a piece of trash away. *She stated she hit head. -Staff had noted a reddened area on the back of her head. *Staff initiated neurological checks. *They had not reported the fall to the SD DOH. *The following had not been included in the investigation: -Her level of orientation. -What level of assistance she required. -When staff had assisted her last. *There had been no documentation of if the care plan had been followed. *There had been no documentation of staff interviews. c. Review of resident 62's 12/9/17 internal fall report revealed: *She had fallen at 11:00 a.m. in her room. *Staff heard her calling for help. *They found her lying on the floor in front of her recliner. *She stated she stood up to look into her dresser, turned, and fell down. *She had complained of right shoulder pain. *Staff initiated neurological checks. *Th… | 2020-09-01 |
| 16 | 16 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2018-02-07 | 657 | D | 0 | 1 | TWBV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure care plans had been revised and updated to reflect the individual care needs for two of seven sampled residents (13 and 62). Findings include: 1. Review of resident 13's 11/21/17 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status score was three indicating her cognition was severely impaired. *She had not demonstrated any physical behaviors. *Verbal behaviors directed towards others had occurred one-to-three days. *Other behavioral symptoms not directed toward others had occurred one-to-three days. *No rejection of care had occurred. *She had wandered one-to-three days. *She required extensive assistance of two staff members to transfer. *She required supervision with assist of one staff member for eating. *She required extensive assistance of one staff member for bathing. *Her [DIAGNOSES REDACTED].>-Hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Other fracture. -[MEDICAL CONDITIONS]. -Non-Alzheimers dementia. *She had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Observation on 2/5/18 from 5:35 p.m. through 6:00 p.m. of resident 13 revealed: *She had been sitting in the dining room waiting for supper at 5:35 p.m. *She was getting agitated and speaking loudly to the two male residents at the table. *At 6:03 p.m. she hit one of the male residents on his hand while yelling at him. *She then picked up her silverware and pulled her arm back as if to throw them at him. *She swore at him several times calling him a name. *Earlier she had been yelling across at the other male resident about his glasses. *At 6:06 p.m. she again started to call the male resident names. *There had been no staff that intervened. Observation on 2/5/18 at 6:13 p.m. of resident 13 revealed: *She was served her food. *She stated she did not want it. *She raised her voice to staff and told … | 2020-09-01 |
| 17 | 17 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2018-02-07 | 658 | D | 0 | 1 | TWBV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to accurately document one of one sampled resident's (7) current situation related to a medication change that had not occurred. Findings include: 1. Review of resident 7's medical record revealed on 2/6/18 the care conference note stated her [MEDICATION NAME] had been decreased in (MONTH) (YEAR) and the [MEDICATION NAME] had been decreased in (MONTH) (YEAR). Interview on 2/7/18 at 3:42 p.m. with the director of nursing (DON), the administrator, and resident care coordinator (RCC) A regarding resident 7 revealed: *They had just discussed the decrease in medication from (MONTH) (YEAR) this past week. *They felt the resident had been exhibiting more behaviors, and they had contacted the physician for her to be seen the next time rounds were done. *They felt the medication needed to be adjusted again and for it to go back to what it was prior to December. *Documentation was requested from the DON at that time for monitoring the effectiveness of both medication changes. Interview on 2/7/18 at 4:00 p.m. with RCC A revealed there had not been a medication change of the [MEDICATION NAME] in (MONTH) (YEAR). She had documented inaccurately in the care conference note. She had looked at the physician order [REDACTED]. She realized after reviewing the chart again the only change to the order had been Do not crush. Adding that phrase changed the date on the order to 12/4/17. She had assumed based on that date the medication had been reduced which was inaccurate. Review of [NAME] [NAME] Potter and Anne Griffen Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., (YEAR), p. 356, revealed: *Documentation is a nursing action that produces a written account of pertinent patient (resident) data, nursing clinical decisions and interventions, and patient responses in a health record. *Nursing documentation needs to be accurate and comprehensive. | 2020-09-01 |
| 18 | 18 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2018-02-07 | 689 | D | 0 | 1 | TWBV11 | Based on observation, interview, and record review, the provider failed to assess the environment and implement interventions for one of one sampled resident (62) who had been identified to be at risk for falls upon admission. Findings include: 1. Review of resident 62's medical record revealed she had been identified to be at high risk for falls, and the provider had not assessed the environment and implemented interventions for the falls. Refer to F657, finding 2. | 2020-09-01 |
| 19 | 19 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2018-02-07 | 740 | D | 0 | 1 | TWBV11 | Based on observation, interview, and record review, the provider failed to ensure one of one sampled resident (13) with behaviors and anxiety received the appropriate care and services. Findings include: 1. Review of resident 13's medical record revealed she had been identified to have behaviors that affected others and behaviors revolving around her bath. The provider failed to implement and document appropriate interventions. Refer to F657, finding 1. | 2020-09-01 |
| 20 | 20 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 550 | D | 0 | 1 | L4FS11 | **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 (61) was engaged in conversation during three of three meal services. *Two of two sampled residents (61 and 78) were provided privacy during personal care. Finding include: 1. Review of resident 61's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Unspecified dementia without (w/o) behavioral disturbances. -Age related [MEDICAL CONDITION] w/o current pathological fracture. -Hypertension. -Vitamin D deficiency. Review of resident 61's 4/2/19 Minimum Data Set assessment revealed: *There was no Brief Interview for Mental Status assessment score due to significant cognitive impairment. *The resident representative was not available for an interview for her daily activity preferences, and the resident was not able to be interviewed. *She was totally dependent upon two staff for assistance with bed mobility, transfers, toilet use, and bathing. *She was totally dependent upon one staff person for locomotion on and off the unit. *She required the extensive assistance of two staff for dressing and personal hygiene. *She required the extensive assistance of one staff person for eating. Observation on 5/7/19 from 7:50 a.m. through 8:27 a.m. in the [NAME] wing dining room revealed: *Certified nursing assistant (CNA) F and CNA G were sitting at dinning room table four. -They were sitting on opposite corners of the table to assist residents with breakfast. *There were four residents sitting at the table needing assistance including resident 61. *CNA F and G were maintaining a conversation between themselves across the table. *CNA G did tell resident 61 what was on her fork one time. *There was no other verbal communication with the resident's by either CNA during that time. Observation on 5/7/19 from 12:18 p.m. through 12:25 p.m. in the [NAME] wing dining room revealed: *CNA G and H were sitting at … | 2020-09-01 |
| 21 | 21 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 574 | E | 0 | 1 | L4FS11 | Based on observation, interview, and policy review, the provider failed to ensure the ombudsman and South Dakota Department of Health information had been posted in a location accessible to the residents, visitors and families. Findings include: 1. Interview with the resident group on 5/8/19 from 10:00 a.m. through 10:30 a.m. revealed: *The residents were unaware of where to find contact information for the Ombudsman. *The residents were not aware they could contact the South Dakota Department of Health directly. Observation on 5/8/19 between 12:30 p.m. and 3:00 p.m. revealed: *The ombudsman's contact information was posted in the foyer of the front door. -The resident's were not able to access this without the assistance of staff. The door from the inside of the building required a code to open. *The ombudsman's contact information was also posted down [NAME] wing on a door. -That information was at eye level when standing. -It would not have been accessible to read from a wheelchair. Interview on 5/8/19 at 11:40 a.m. with the regional ombudsman revealed: *She had asked for the ombudsman information to have been placed down each hallway. *She had asked for the ombudsman information to be more available to the residents. *The ombudsman contact information was only available in the foyer, that had a secured door from the inside of the facility going out into the foyer. Interview of 5/8/19 at 2:48 p.m. with the social service director and the social service assistant P revealed: *There were cards in their office for the ombudsman and the poster was in the foyer. *They agreed the residents could not access the poster with the ombudsman's contact information. Interview on 5/8/19 at 2:58 p.m. with the administrator revealed: *The ombudsman's contact information was posted in the front foyer and on [NAME] wing by the back door. *She agreed residents would need help to access the ombudsman's contact information in the foyer. *She was not aware of the ombudsman asking the facility to have her contact information more acc… | 2020-09-01 |
| 22 | 22 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 584 | D | 0 | 1 | L4FS11 | Based on observation, interview, and policy review, the provider failed to ensure: *One (hallway A) of four hallways was clean and in good repair. *Mechanical lifts stored in resident's rooms in one of four hallways (E wing) had prevented residents access to their items. Findings include: 1. Observation on 5/9/19 from 7:20 a.m. through 9:00 a.m. of residents' rooms (513, 514, 515, 516, 517, and 518) revealed: *There were between three and ten tan tiles in the door way of each resident's room. -There was approximately 1/8 to 1/4 inch gap between the tan tiles in the door ways and the white tiles in the rooms. -Dust and grime could be scraped out of those gaps with a fingernail. -Dust build-up in the corners of each door way that could be wiped off the floor. -One door way was rusted at the bottom and had started staining the tiles that were next to it. -One door had three gouges across the bottom of the door deep enough that no varnish remained. -There was a white substance splattered on two of the six doors approximately one fourth of the way up and all the way across the bottom. -There were two rooms that had tiles cracking along the top of the tiles. *There were five residents' rooms with brown plastic protectors on the doors. -They were secured to the doors with fifteen screws. -They were not sealed and left gaps between the door and the plastic piece. -The edges of the plastic were sharp. -One plastic piece was broken on the corner under the screw that was holding it to the door. Interview on 5/9/19 at 8:41 a.m. with the head of housekeeping and laundry revealed: *They had been short staffed in housekeeping with only two housekeepers to clean the entire facility. *With only having two housekeepers for the facility they had not been able to get all of the cleaning done. *They had made residents' rooms and dining rooms their priority for cleaning. *The white splatter on the doors was floor wax, and she had been unable to get it cleaned off the doors. Interview on 5/9/19 at 8:49 a.m. with the maintenance man rev… | 2020-09-01 |
| 23 | 23 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 658 | D | 0 | 1 | L4FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and protocol review, the provider failed to ensure documentation was completed for one of four sampled residents (18) who had a pressure ulcer. Findings include: 1. Review of resident 18's medical record revealed: *A telephone order dated 1/27/19 at 4:30 p.m. from a physician (name). *Order stated to apply Allevyn to opened area on the coccyx. -Change every (q) three days and as needed (PRN) until healed. *Minimum (MDS) data set [DATE] indicated a stage 2 pressure ulcer. *There had not been any: -Additional nursing progress notes regarding that pressure ulcer. -Documentation of notification to the family or physician. -Measurements of the pressure ulcer. -Weekly skin assessments. -Initial event report. *Review of a 2/12/19 at 12:40 p.m. interdisciplinary progress note revealed: *Category: Skin assessment, physician visit. -Primary care physician (name) was there for an acute visit and assess the coccyx/buttock pressure sore. -Buttock is chapped, dry peeling skin with an open area mid coccyx noted. -Allevyn dressing changed after assessment completed. Interview on 5/08/19 at 9:50 a.m. with the director of nursing (DON) regarding resident 18 revealed: *The DON confirmed the above findings. *She saw a telephone communication from the physician dated 1/27/19 that stated to change the dressing q 3 days or as needed if it came off. *Based on that information she believed the pressure ulcer to the resident's coccyx had started on that date. *She stated she did not know why there had not been: -An initial event report. -Documentation in the pressure ulcer log. -Documentation of notification to the physician. -Documentation of notification to the family. Review of the provider's revised 3/24/17 Pressure Ulcer/Skin Breakdown-Clinical Protocol revealed: *If skin breakdown or pressure ulcer was discovered, the following would be notified immediately: -Attending physician -Resident's responsible party. -Wing coordinator … | 2020-09-01 |
| 24 | 24 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 679 | E | 0 | 1 | L4FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure four of seven sampled residents (24, 52, 61, and 76) had individualized and meaningful activities. Findings include: 1. Review of resident 52's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Age related [MEDICAL CONDITION]. -Vitamin D deficiency, unspecified. -Heart failure. Review of resident 52's 3/20/19 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was three indicating her cognition was severely impaired. *It was very important for her to: -Have books, newspapers, and magazines to read. -Be around animals such as pets. -Keep up with the news. -Go outside and get fresh air. -Participate in religious services. *It was somewhat important for her to: -Listen to music. -Do things with groups of people. -Do her favorite activities. Review of resident 52's current undated care plan revealed her interventions for activities were: *Inform of daily activities and assist with wheelchair to and from activities of choice. *Activity group interests: games (BINGO), crafts, parties, religious activities Methodist. *Leisure activity interests: TV, visiting, phone, watching/listening to sports. Observation on 5/7/19 at 3:00 p.m. and again at 4:02 p.m. of resident 52 revealed: *She was sitting in her recliner in her room and was awake. -There was no television in her room, and there was no music playing. *At 3:00 p.m. there was a puzzle activity going on in the Independence dining room. *At 4:00 p.m. they were gathering residents for another activity in the Independence dining room, but she had not been invited. *She had not participated in either of those activities. Interview on 5/7/19 at 4:25 p.m. with resident 52 in her room revealed: *The activity staff person did not come in to ask her to join the activity. *There had been no TV in her room, and there was no musi… | 2020-09-01 |
| 25 | 25 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2019-05-09 | 880 | E | 0 | 1 | L4FS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to: *Ensure appropriate hand washing was done for: -One of two residents (89) wound care observations preformed by wound care nurse I . -Two random residents (18 and 42) during perineal care performed by certified nursing assistants (CNA) K, L, and M. *Provide appropriate catheter care for one of two residents' (144) observed catheter care done by CNAs A and B. *Identify and implement transmission-based precautions for one of one sampled resident (92) to prevent the spread of infection. *Follow cleaning procedure for two of three observed tub cleanings (D and [NAME] wings) by CNAs D and E. *Properly store tub disinfectant chemicals and personal care items in all four tub rooms. *Properly clean mechanical lifts between residents' (51, 78, and 85) use for two of two missed mechanical lift cleaning opportunities done by CNAs M and O. Findings include: 1. Observation and interview on 5/8/19 from 2:52 p.m. through 3:17 p.m. with wound care nurse I regarding resident 89 revealed she: *Had been seeing her since last September. *Stated she had used hand sanitizer when she entered the room. *Assisted repositioning the resident as the pressure ulcer was on her coccyx. *Gloved and took off the resident's soiled dressing. *Took out supplies from her canvas bag. *Measured depth with a Q-tip. -Took her pen out of her bag and wrote down measurements on a paper. *She continued with the same gloves on and cleansed the wound with one 4 x (by)4 sponge and wound cleanser. -Wiped several times over the wound. *Packed her wound with one 2x2 sponge pad, ointment applied with a Q-tip. *Opened and applied a [MEDICATION NAME] dressing to the wound. *Removed her gloves. *Cleaned up the area, threw away garbage, and put supplies in a plastic Ziploc bag in her canvas bag. *Then she put gloves on and pulled up the her pajama pants. *Moved the bed back in place. *Touched the resident's h… | 2020-09-01 |
| 26 | 26 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2016-12-07 | 281 | D | 0 | 1 | EGJW11 | Based on observation, interview, record review, and procedure review, the provider failed to follow professional nursing standards to administer a tube feeding for one of one sampled resident (8) regarding tube placement and elevated head position. Findings include: 1. Observation and interview on 12/6/16 at 2:45 p.m. of registered nurse (RN) A working with resident 8 revealed: *He had a gastrostomy jejunostomy (G J) tube located in the abdomen. *He was lying flat in his bed. *He received a liquid nutritional supplement four times a day along with medications through the g portion of the tube, that went into the stomach. *She prepared the resident's medication and nutritional supplement. *Without checking for tube placement she gave his medication and the supplement through the G port of the tube. *She had not elevated the head of the bed to prevent possible aspiration into the lungs. Review of resident 8's medical records revealed: *His admitted was 11/10/15. *He had a stroke and was unable to swallow well. *He also took food orally. *Verification of the G J tube, and his supplement and medications were to go through the g portion of the tube. *An addition to his care plan dated 10/26/16 revealed the head of the bed was to be elevated at all times. Review of the provider's 8/16/12 Enteral Tube Feeding via Syringe (Bolus) procedure revealed: *Elevate head of bed 30-45 (degrees) (semi-Fowler's position). *Verify placement of tube. *Initiate feeding. Interview on 12/6/16 at 5:45 p.m. with the director of nursing regarding resident 8's tube feeding revealed: *She agreed the nurse should have checked the tube placement before giving anything through it. *She agreed the head of his bed should have been elevated. Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo.,2013, p.1032, revealed: *Place patient in high-Fowler's position or elevate head of bed at least 30 (preferably 45) degrees. Elevated head helps prevent aspiration (Kenny and Goodman, 2010). *Verify tube pla… | 2020-09-01 |
| 27 | 27 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2016-12-07 | 329 | D | 0 | 1 | EGJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure one of nine sampled residents (11) who received an antipsychotic medication had an appropriate indication for the use of it and had an attempt at a gradual dose reduction (GDR). Findings include: 1. Review of resident 11's (MONTH) (YEAR) physician's orders [REDACTED]. *[MEDICATION NAME] 125 milligrams (mg) twice daily (BID); ordered date 12/8/15. *Donepezil [MEDICATION NAME] 10 mg one tablet at bedtime; ordered date 12/8/15. *[MEDICATION NAME] 50 mg for mood; ordered date 12/8/15. *[MEDICATION NAME] 0.25 mg one tablet twice daily (BID) for restlessness and agitation; ordered date 12/8/15. -The targeted behaviors for use of the [MEDICATION NAME]: repetitive verbalizations, smearing feces, agitation, repetitive movements. Review of resident 11's 9/7/16 through 12/6/16 behavior monitoring documentation revealed she had not exhibited any physical, verbal, or other behaviors. Review of resident 11's interdisciplinary progress notes revealed: *7/13/16 Care Conference: She has no mood or behaviors noted during this assessment period. She is receiving [MEDICATION NAME] and [MEDICATION NAME] with dx (diagnosis) Anxiety and Agitation. *7/14/16: Mood essentially stable. Can become easily irritated or flustered and can seem physically aggressive to caregiver however seems more r/t (related to) lack of comprehension and difficulty in expressing self d/t (due to) cog (cognitive) deficits. *9/22/16: Mood fairly stable .has occas (occasional) periods of mild aggression which seems to be r/t inability to express needs effectively. *9/27/16 Care Conference: She has no mood or behaviors noted during this assessment period. She is receiving [MEDICATION NAME] and [MEDICATION NAME] with dx Anxiety and Agitation. Review of physician's progress notes from (MONTH) (YEAR) through 12/7/16 revealed: *She was seen every sixty days. *No GDR had been discussed or documented. Review of resid… | 2020-09-01 |
| 28 | 28 | AVANTARA HURON | 435020 | 1345 MICHIGAN AVENUE SW | HURON | SD | 57350 | 2016-12-07 | 441 | D | 0 | 1 | EGJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to follow appropriate infection control technique: *Upon entering and before exiting on of one randomly observed resident's (2) room by staff development coordinator B and dietary aide C. *During one of four sampled resident's (2) observed dressing change. Findings include: 1. Observation on 12/5/16 at 4:20 p.m. on B-wing during initial tour revealed: *Resident 2's room had an isolation cart that sat directly outside the door. *There was a note on that door to check with nursing staff prior to entering. *Staff development coordinator B and dietary aide C were observed entering the resident's room without washing their hands. *Staff development coordinator B answered a question for the resident and washed her hands upon exiting the room. *Dietary aide C had been delivering fresh water to all the residents on B-wing. *He removed the resident's water mug that had been sitting on her bedside table, walked out of her room, and placed it on a cart. *Dietary aide C had not performed hand hygiene before he left the resident's room. *He then proceeded to enter the next resident's room without sanitizing or washing his hands. *He removed that resident's water mug and placed it on the cart. *He then grabbed a fresh water mug, entered that resident's room again, and replenished the resident with a new water mug. Interview immediately following the above observation with registered nurse (RN) D regarding the above isolation room in the B-wing revealed: *Resident 2 was on contact isolation precautions for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE). *It was isolated to the resident's urine. 2. Observation on 12/6/16 at 10:10 a.m. with RN A while she performed a dressing change on resident 2 revealed: *She retrieved a bag of dressing supplies from the medication cart outside the resident's room. *She then put on a gown. *There was a hand sanitizer dispenser mounted on the wall a… | 2020-09-01 |
| 29 | 29 | AVERA ROSEBUD COUNTRY CARE CENTER | 435029 | 300 PARK STREET POST OFFICE BOX 408 | GREGORY | SD | 57533 | 2020-01-29 | 880 | D | 0 | 1 | BDC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure proper infection control techniques were followed during nursing procedures for: *One of one sampled resident (11) during one of three observed dressing changes performed by two of two registered nurses (RN) (D and E). *Two of two randomly observed nebulizer (neb) cleanings for resident 33 cleaned by two of two RNs (B and F). Findings include: 1. Observation on 1/29/20 at 10:30 a.m. of RNs D and [NAME] during a dressing change for resident 11 revealed RN D: *Applied hand gel then lifted a cloth covering from a wound kit that was placed on a cart outside resident 11's door. *With ungloved hands she: -Opened a plastic bag, removed several unpackaged gauze sponges from the package, and placed them in her opposite ungloved hand. -Reached into the wound kit to remove a packaged dressing, packaged wound barrier wipes, and an unpackaged paper wound measuring tool. -Brought those wound supplies into the resident's room. -Placed them on the resident's bedside table directly on top of a pile of mail without placing a barrier between the wound supplies and the mail. *Washed her hands and put on gloves. With those gloves on she: *Removed the soiled dressing. *Picked up the paper measuring tool and placed it on the wound to measure it. *Cleansed the wound using the gauze pads. *Opened the barrier cream and applied it to the wound area. *Removed her gloves and applied hand gel. She then put on clean gloves and with those gloves she: *Picked up the dressing package from on top of the mail. *Opened the package and applied the dressing to the buttocks. *Removed the gloves and washed her hands. Interview at that time with RNs D and [NAME] regarding the above dressing change confirmed: *Gloves should have been worn to remove unpackaged supplies from the wound kit. *A barrier should have been placed between the clean wound supplies and the mail on the table. *Package… | 2020-09-01 |
| 30 | 30 | AVERA ROSEBUD COUNTRY CARE CENTER | 435029 | 300 PARK STREET POST OFFICE BOX 408 | GREGORY | SD | 57533 | 2018-12-19 | 657 | D | 0 | 1 | ZMYV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to review and revise care plans to address residents' current needs for 2 of 12 sampled residents (26 and 37). Findings include: 1. Review of resident 26's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had a history of [REDACTED]. *His 11/14/18 quarterly Minimum Data Set (MDS) assessment Brief Interview of Mental Status (BIMS) cognitive score had been zero indicating severe cognitive impairment. *His current care plan had interventions that included turning and repositioning every two hours. -That included toileting transfers. Observations of resident 26: *On 12/17/18 from 7:45 a.m. through 11:10 a.m. and 2:00 p.m. through 5:30 p.m. revealed he had been sitting in his chair. He had not changed position or off-loaded his coccyx area. *On 12/17/18 from 3:30 p.m. through 6:30 p.m. in the hallway and dining room revealed he had been sitting in his chair. He had not changed position or off-loaded his coccyx area during that time. Interview on 12/19/18 at 8:50 a.m. with the director of nurses revealed she agreed: *Resident 26 had not be repositioned and off-loaded from his coccyx area during the above time frames. *The care plans needed to be updated. 2. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 37's 11/26/18 admission MDS assessment revealed: *Her BIMS score had been three indicating severe cognitive impairment. *She was an extensive assistance of one staff member with toileting and personal hygiene needs. -She had been able to indicate toileting needs. -She was always continent of bowel. *She had a recent short stay hospitalization related to rule out [MEDICAL CONDITION], UTI, and constipation from 12/7/18 to 12/11/18. *Her 11/26/18 care plan did not have a problem area, goal, or interventions related to her constipation. Interview on 12/… | 2020-09-01 |
| 31 | 31 | AVERA ROSEBUD COUNTRY CARE CENTER | 435029 | 300 PARK STREET POST OFFICE BOX 408 | GREGORY | SD | 57533 | 2018-12-19 | 690 | D | 0 | 1 | ZMYV11 | **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 (37) had appropriate bowel management. Findings include: 1. Observation on 12/19/18 at 7:05 a.m. of certified nurse aide (CNA) A performing morning care with resident 37 revealed: *She was able to answer yes and no questions related to her daily activities. *She had been able to state no when asked if she needed to have a bowel movement. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *She had [DIAGNOSES REDACTED]. and history of urinary tract infection [MEDICAL CONDITION]. *Her 11/26/18 admission Minimum Data Set (MDS) assessment revealed: -A Brief Interview of Mental Status score had been three indicating severe cognitive impairment. -She --Was an extensive assistance of one staff member with toileting and personal hygiene needs. --Had been able to indicate toileting needs. --Had always been continent of bowel. *She had a recent short stay hospitalization related to rule out [MEDICAL CONDITION], UTI, and constipation from 12/7/18 to 12/11/18. *She had not had a bowel movement (BM) for seven days. Interview on 12/19/18 at 7:30 a.m. with CNA A regarding resident 37's toileting habits revealed: *She was able to tell staff when she needed to have a BM. *She preferred to use the toilet and not go in her brief. Interview on 12/19/18 at 9:01 a.m. with CNA B regarding bowel management revealed: *Resident 37 was able to ask to use the toilet. *Every morning in report CNAs were given a list of residents who had not had a BM in three days. -The night nurse printed the report for day shift. *The nurse would inform the CNAs if a resident were to receive a suppository or medication to assist with a BM. -CNAs would be aware of who would need immediate assistance with toileting. *When the resident had results the CNA charted in the computer under Bowel Record. Interview on 12/19/18 at 10:30 a.m. with the… | 2020-09-01 |
| 32 | 32 | AVERA ROSEBUD COUNTRY CARE CENTER | 435029 | 300 PARK STREET POST OFFICE BOX 408 | GREGORY | SD | 57533 | 2018-12-19 | 758 | D | 0 | 1 | ZMYV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure appropriate stop orders and clinical needs were in place for the use of as needed (PRN) [MEDICAL CONDITION] medication for two of five sampled residents (21 and 26) receiving psychoactive medication. Findings include: 1. Review of resident 21's medical record revealed physician's orders [REDACTED].>*[MEDICATION NAME] 100 milligram (mg) by mouth at HS (bedtime) for dementia. *On 11/16/18 via fax for [MEDICATION NAME] 2.5 mg PO (by mouth) q (every) 8 hours prn agitation. *There had not been: -A stop date for the 11/16/18 order. -Documentation by the physician indicating rationale for the PRN antipsychotic medication to be extended beyond fourteen days. Review of the (MONTH) (YEAR) Gradual Dose Reduction-Psychopharmacological Medication form regarding the [MEDICATION NAME] for resident 21 revealed: *Pharmacy recommended a dose decrease. *The physician response indicated no change. -That action required the physician to provide clinical contraindication or exempt condition. -No information had been provided. 2. Review of resident 26's medical record revealed physician's orders [REDACTED]. *Signed and dated on 12/3/18 for [MEDICATION NAME] 0.5 mg p.o. PRN every six hours for agitation. *There had not been: -A stop date for the order of 12/3/18. -Documentation by the physician that had rationale for the PRN antipsychotic medication to be extended beyond fourteen days. Interview on 12/19/18 at 8:50 a.m. with the director of nursing revealed she: *Agreed there was not an effective procedure in place for management of PRN antipsychotic medication orders. *Had educated the physicians on antipsychotic PRN orders but had not kept any documentation of that education. *Had been trying to educate the nurses to enter a fourteen day stop date for all PRN antipsychotic medications ordered. *Agreed the physicians should have been ordering the stop dates for the PRN antipsychotic… | 2020-09-01 |
| 33 | 33 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2019-03-13 | 554 | D | 0 | 1 | 0JC611 | **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 sampled residents (23 and 27) who self-administered medications had been assessed. Findings include: 1. Observation and interview on 3/11/19 at 3:30 p.m. with resident 23 revealed she had a unit dose [MEDICATION NAME] nebulizer treatment in her hand. She stated the nurse would give her the unit dose before it was due to be taken. She also had a [MEDICATION NAME] hand held inhaler, saline nasal spray, and [MEDICATION NAME] nasal spray on her overbed table. She stated she also self-administered those medications. Review of resident 23's medical record revealed: *She only had an order to self-administer her [MEDICATION NAME]. *The last self-administration assessment had been completed on 3/1/18. Review of resident 23's care plan for self-administration of medications initiated on 5/18/16 revealed: *Focus: I am able to self administer my nebulizer medication. *Goal: I will demonstrate my ability to correctly document and self administer my nebulizers through the next quarter. *Interventions included: I will participate in quarterly self administration assessments to qualify me to continue my self administration privileges. Interview on 3/13/19 at 1:29 p.m. with the Minimum Data Set (MDS) coordinator agreed no assessments had been completed since 3/1/18. The director of nursing and herself had changed the process, so the nurses were assigned that assessment. She stated the timing of the assessments was placed in the treatment administration record (TAR). When she looked on resident 23's (MONTH) and (MONTH) 2019 TARs those assessments did not show up to complete them. She agreed there was only a physician's orders [REDACTED]. 2. Observation on 3/12/19 at 8:04 a.m. of unlicensed assistive personal (UAP) A while she administered medication to resident 27 revealed: *She:-Left two [MEDICATION NAME] 80 milligram (mg) tablets in a plastic medication cup on his ta… | 2020-09-01 |
| 34 | 34 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2019-03-13 | 657 | E | 0 | 1 | 0JC611 | Based on observation, interview, record review, and policy review, the provider failed to review and revise care plans to reflect the current needs of 3 of 13 sampled residents (7, 19, and 31). Findings include: 1. Observations and record review of resident 31 revealed: *On 3/11/19 from 3:30 p.m. through 4:30 p.m. and from 5:00 p.m. through 5:30 p.m. while in her room she: -Sat in her wheel chair beside her bed. -Made no attempts to move herself out of her wheel chair or leave her room. -Was taken to the dining room at 4:30 p.m. -Was taken to her room by an unidentified certified nurse aide (CNA) after her evening meal. --Continued to sit in her chair and made no attempts to move out of her chair or leave her room. *On 3/12/19 from 8:00 a.m. through 11:30 a.m. and again from 2:00 p.m. through 4:30 p.m. she had been in her wheel chair sitting beside her bed or laying in her bed. She made no attempt to self-propel herself, move, or leave her room while in her wheel chair. Review of resident 31's 2/22/19 care plan revealed: *A focus area: elopement risk, revised 10/29/16 that stated: I am an elopement risk/wanderer AEB (as exhibited by) history of attempts to leave facility unattended, impaired safety awareness, failed trial on non-secure unit 10-25 to 10-29-2016. -The provider had not had a secured unit for no less than one year. *For activities of daily living she required limited to extensive assistance for bed mobility, transfers, locomotion, and to use the bathroom. Review of resident 31's weight record revealed a 10% weight loss change from 8/27/18 through 2/19/19. There had not been a focus area or interventions added to the resident's care plan specific to weight loss. 2. Observation and interview on 3/12/19 at 10:35 a.m. of resident 19 during morning care revealed: *CNA A and nurse aide (NA) B transferred her to bed from her wheel chair using the total lift. *They both agreed that they routinely used the total lift on resident 19. Interview on 3/12/19 at 11:15 a.m. with physical therapist C regarding reside… | 2020-09-01 |
| 35 | 35 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2019-03-13 | 677 | D | 0 | 1 | 0JC611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to provide oral care for two of two sampled residents (41 and 204). Findings include: 1. Observation of resident 41 on 3/12/19 from 7:50 a.m. through 8:50 a.m. during personal care revealed certified nursing assistant (CNA) G had not provided any oral care. Interview on 3/12/19 at 10:00 a.m. with resident 41 revealed: *She was unable to use her left arm due to a stroke. *She was able to do some of her own oral care after set-up. *Staff would have helped if she could not complete all of her oral care herself. *CNA G did not assist her to brush her teeth this morning. Interview on 3/13/19 at 10:49 a.m. with resident 41 revealed she had not been assisted with any oral care this morning. Observation on 03/13/19 at 10:50 a.m. of resident 41's toothbrush and basin revealed they were dry. Interview on 3/13/19 at 2:00 p.m. with the director of nursing revealed staff should have assisted resident 41 with her oral care. She stated that had been addressed before and signs had been placed in residents' rooms who required assistance. She agreed resident 41 did have one of those signs. Review of resident 41's 11/6/18 care plan for her activites of daily living revealed: *Focus: I have a history [MEDICAL CONDITION] and my left side is flaccid. I am not able to complete my daily care activities and I need your assistance. *Goal: I will complete my daily care activities by accepting your assistance through my next review date. *Interventions included: -PERSONAL HYGIENE/ORAL CARE: I need limited to extensive assist to perform hygiene activities. I have my own teeth and need you to assist me to clean them. 2. Observations and interviews on: *3/12/19 at 8:15 a.m., 11:00 a.m., 2:00 p.m., and 3:48 p.m. with resident 204 and his wife revealed: -They both stated he had not been assisted with or provided oral hygiene during the above times. -His wife stated: --She knew that, becaus… | 2020-09-01 |
| 36 | 36 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2019-03-13 | 690 | D | 0 | 1 | 0JC611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to ensure one of one sampled resident (41) was provided the opportunity to maintain or improve her bladder and bowel continence. Findings include: 1. Observation on 3/12/19 from 7:50 a.m. through 8:55 a.m. of resident 41 during personal care and a full lift transfer revealed: *She had previously received perineal care and her incontinent brief had been changed. *Certified nursing assistant (CNA) G came into the room and checked to see if the resident had been incontinent after approximately one-half hour. *She told CNA G she had not urinated since her brief had been changed. *CNA G had not offered her a chance to use a bedpan, commode, or the bathroom. Review of resident 41's medical record revealed: *She had a urinary catheter from 4/27/18 through 11/1/18 when it was discontinued. *A voiding trial to check post-void residuals was conducted from 11/1/18 through 1/7/19. Review of resident 41's 11/6/18 care plan for her activities of daily living revealed: *Focus: I have a history [MEDICAL CONDITION] and my left side is flaccid. I am not able to complete my daily care activities and I need your assistance. *Goal: I will complete my daily care activities by accepting your assistance through my next review date. *Interventions included: -TOILET USE: I need extensive assist to perform toileting activities. My foley catheter has been removed to see if I can tolerate/urinate w/o (without) it. I am sometimes incontinent. I need you to perform bladder scans post void until it can be determined that I am adequately voiding. I am continent of bowel. -TRANSFERS: I am dependent upon staff to transfer me using a Hoyer lift. Review of resident 41's Minimum Data Set (MDS) quarterly reviews completed on the following revealed: *11/1/18: Required extensive assistance of one staff for transfers and toilet use. -She had a urinary catheter and was continent of bowel. *2/1/19: Required extensi… | 2020-09-01 |
| 37 | 37 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2019-03-13 | 880 | E | 0 | 1 | 0JC611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure proper handwashing, glove use, wound care, and personal protective equipment procedures, and mechanical lift sling maintenance had been followed: *For one of one observed certified nursing assistant (CNA) (G) during personal care for resident 41. *For one of one observed resident (19) on contact precautions. -Designed for residents known or suspected to be infected with microorganisms that could have been transmitted by direct contact with the resident or environment. *For three of three observed registered nurses (RN) (D, E, and H) during topical medication administration and dressing changes for three of three observed residents (9, 19, and 40). Findings include: 1. Interview on 3/11/19 at 5:44 p.m. with RN H regarding resident 9 and what precautions were required revealed: *She stated precautions were only required if doing direct resident care. *Resident 9 had a history of [REDACTED]. *Gloves and gowns were all that would be required during wound care. 2. Observation on 3/12/19 from 7:55 a.m. through 8:55 a.m. of CNA G during personal care for resident 41 revealed: *CNA G entered the room and with no hand hygiene she: -Put on the resident's support hose. -Checked to see if her incontinent brief needed to be changed. -She then went and put on gloves then checked the incontinent brief again. -Removed those gloves and did no hand hygiene during the entire observation. *Resident 41 was transferred from the bed to her wheelchair with a total lift. -The sling used had come from a storage bag on the lift and was put back in that storage bag after the transfer. *Interview with CNA G at 8:40 a.m. revealed there was a shortage of slings, so they were used by multiple residents each day. 3. Observation on 3/12/19 from 8:20 a.m. through 8:30 a.m. of RN H during topical medication administration revealed: *RN H entered the resident's room with three small … | 2020-09-01 |
| 38 | 38 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 550 | J | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, policy review, and admission packet review, the provider failed to ensure one of one sampled resident's (49) personal space and privacy was protected from one of one sampled resident (17) who had a history of [REDACTED]. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment.*For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center.*For policy and procedure review: -Review and revision of the following policies were completed and revis… | 2020-09-01 |
| 39 | 39 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 600 | J | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to ensure all residents and staff were free from the verbal, physical, and sexually abusive behaviors from one of one sampled resident (17). NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment. *For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center. *For policy and procedure review: -Review and revision of the following policies were completed and revisions were made as deemed n… | 2020-09-01 |
| 40 | 40 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 609 | E | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and policy review, the provider failed to investigate and report incidents with injury for 4 of 13 sampled residents (17, 41, 42, and 53) according to South Dakota Department of Health (SD DOH) guidelines. Findings include: 1. Review of resident 41's medical record, incident reports, and investigations from her admission on 8/1/17 through 3/15/18 revealed:*She was cognitively impaired and had multiple falls and injuries. *She was dependent on staff for assistance with personal care. *On 10/24/17 she had a fall that resulted in a right shoulder dislocation and had to be sent to the hospital for treatment. -That fall had no investigation and had not been reported to the SD DOH. *On 1/7/18 she was involved in a resident-to-resident altercation. -That incident had no investigation and had not been reported to the SD DOH. *On 1/22/18 she had a bruise found on her left great toe that was of unknown origin. -There was no investigation to rule out abuse, and that had not been reported to the SD DOH. *On 2/19/18 discoloration was noted to the back of her head, both heels, and buttocks during a bath. -There was no investigation into those areas, and they had not been reported to the SD DOH. --The heels were later identified as pressure injuries. *On 2/26/18 a blister-like spot was noted to the tip of her right great toe. -The nurse wrote .not going to classify as pressure area . -There was no investigation into the cause of that area, and it had not been reported to the SD DOH. Refer to F610, finding 10. 2. Review of resident 53's medical record, incident reports, and investigations from his admission on 2/14/18 through 3/15/18 revealed:*He had cognitive impairment and was dependent on staff for personal care. *On 2/22/18 .Bruised area to left shin measuring 2.1 cm (centimeters) x (by) 1.1 cm covered with ABD pad and cling to secure for protection. -There was no mention of how that bruise occurred or if it was a new… | 2020-09-01 |
| 41 | 41 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 610 | F | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and policy review, the provider failed to complete and fully investigate residents' incidents for 13 of 13 sampled residents' (3, 5, 6, 17, 33, 36, 37, 41, 42, 47, 53, 57, and 109) reviewed with incident reports and investigations. Findings include: 1. Review of resident 3's fall incident investigation reports revealed: *A fall report dated 7/11/17 completed by registered nurse (RN) G stated the resident had:-Fallen onto her bottom in the bath house. -The following areas on the incident investigation report had not been completed: --Mental status. --Physiological factors. --Predisposing situation factors. -There had been only one fall progress note regarding the 7/11/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/18/17 completed by licensed practical nurse (LPN) N stated the resident had: -Fallen when She missed the toilet and fell straight on her butt. Denies hitting head. -The following areas on the incident investigation report had not been completed: --Injuries Observed at Time of Incident. --Level of pain. --Mental status. --Predisposing environmental factors. -There had been only one fall progress note regarding the 7/18/17 incident in her medical record. -There had been no documentation of an investigation having been completed. *A fall report dated 7/20/17 completed by RN T stated the resident had: -Been found by staff sitting on the middle of the floor in her room. She denied hitting her head. She stated I was getting up to ask someone about lunch. -The following areas of the incident investigation report had not been completed: --Injury type No Injuries observed at. --Mental status. --Predisposing environmental factors. --Predisposing situation factor. -There had been no fall progress notes regarding the 7/20/17 incident in her medical record. -There had been no documentation of an investigation ha… | 2020-09-01 |
| 42 | 42 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 657 | E | 0 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure 6 of 13 sampled residents (5, 21, 33, 37, 41, and 53) had their care plans followed, updated, and revised timely to reflect their current status and care needs. Findings include: 1. Observations, interview, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 5 revealed:*Her 3/27/18 care plan had not been updated timely related to her falls and interventions for them. Refer to F689, finding 2. 2. Observations, interview, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 41 revealed her 3/14/18 care plan had not been: *Updated timely related to her falls and interventions for them. *Updated to reflect her current physician's orders [REDACTED]. *Followed by staff related to her fall and pressure ulcer interventions. Refer to F686, finding 1. Refer to F689, finding 1. Observation, interview, and review of the CNA cheat sheet on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during and following resident 41's personal care revealed: *The resident was wearing compression stockings to both legs and slipper socks on her feet. *She had no dressings in place to both of heel pressure injuries. -CNA I was not aware she was supposed to have dressings on her heels. *She was not wearing the foam boots that morning. -The CNA thought she only needed to wear her boots when she was in bed. *The CNAs used a cheat sheet as a reference for how to take care of the residents. *She was the person who updated those cheat sheets with input from the nurses. *CNAs also had access to review the residents' care plan in the electronic medical record. *She agreed residents' care plans and cheat sheets should have been updated to their current status and needs. *The cheat sheet for resident 41 included: -[NAME] hose on … | 2020-09-01 |
| 43 | 43 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 686 | H | 0 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, manufacturer's review, and policy review, the provider failed to ensure four of five sampled residents (21, 41, 47, and 53) who required staff assistance with care had not developed facility acquired pressure injuries. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had short and long term memory problems. *Her decision making ability was severely impaired. *Her [DIAGNOSES REDACTED]. *She was dependent on the staff to: -Anticipate her care needs. -Initiate and implement interventions to ensure her health and safety. *She developed facility acquired pressure injuries to both her heels on 2/19/18. -She also had skin concerns to both her great toes. Observation on 03/13/18 at 08:17 a.m. of resident 41 revealed: *She was laying in bed on her right side with her face covered with blankets. *She had one foam heel boot sitting on top of the covers. -It was not on her foot. Interview and record review on 03/13/18 at 10:09 a.m. with licensed practical nurse (LPN) D regarding resident 41 revealed he:*Was her charge nurse that day. *Was a traveling nurse and had been working there since 2/1/18. *Stated she had pressure injuries and treatments of: -Daily left heel and right heel pressure injury monitoring by the nurse. -A blister area to her right great toe. -[MEDICATION NAME] dressing to her left heel suspected deep tissue injury to be changed every three days as needed. -[MEDICATION NAME] dressing to her right heel suspected deep tissue injury to be changed every three days and as needed. *Stated he was already done with her treatments for the day. *Stated her [MEDICATION NAME] dressing changes were due to be changed on 3/14/18. -The surveyor requested to observe that dressing changed and he agreed stating he would be working again. Observation and interview on 03/13/18 at 11:06 a.m. with certified nursing assistant (CNA) supervisor I during res… | 2020-09-01 |
| 44 | 44 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 688 | D | 0 | 1 | CZRE11 | **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 (21) who had limited mobility had been screened and/or placed on a restorative program (RC) to maintain her range of motion (ROM) and physical abilities. Findings include: 1. Review of resident 21's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to assist her with all activities of daily living (ADL). *She had a Brief Interview Mental Status (BIMS) score of fourteen indicating she had good memory recall. *What activities and meals she had participated in outside of her room was her choice. *She had: -Therapy services for strengthening upon admission to the facility. --Those services had been discontinued d/t (due to) the resident's refusal to participate. *No documentation to support the therapy services had referred her for a RC program to ensure her current mobility status was maintained. Observation and interview on 3/12/18 at 5:22 p.m. of resident 21 revealed: *She had appeared: -Very thin, weak, frail, and her hair was unkempt. -To be able to move her arms without difficulty, but no spontaneous movement of her legs was observed. *She had been: -Laying in her bed resting. -Awake and talked very little when spoken to. *The head of her bed had been elevated to approximately thirty-five degrees. *She had scooted down in the bed so her chin rested on her chest. *Her feet had been hanging over the foot board that was attached to the bed. Continued observation and interview on 3/12/18 at 5:34 p.m. with resident 21 revealed: *An unidentified staff member brought a tray in containing her supper. *The unidentified staff member: -Placed the supper tray on the bedside table and positioned it in front of the resident. -Rolled the head of her bed up further. -Had not: --Attempted to reposition the resident or asked the resident if she would like to be moved up … | 2020-09-01 |
| 45 | 45 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 689 | J | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > [NAME] Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (17) who had verbal, physical, and sexually abusive behaviors had been adequately supervised to protect the other residents from harm. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment. *For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center. *For policy and procedure review: -Review and revision of the following policies were comple… | 2020-09-01 |
| 46 | 46 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 700 | D | 0 | 1 | CZRE11 | Based on observation, interview, and record review, the provider failed to ensure assessments had been followed for two of two sampled residents (41 and 53) who had repositioning bars on their beds. Findings include: 1. Observation of resident 41 on 03/13/18 at 08:19 a.m. revealed she was laying in her bed. There were repositioning bars on both sides near the head of her bed. Review of resident 41's medical record revealed: *Her 3/13/18 care plan had no mention of repositioning bars. *Her 8/1/17 Bed Cane (Repositioning Bar) Assessment indicated: -She had none on her bed. -At this time, bed canes are not recommended for Pt (patient/resident) due to Pt is able to complete bed mobility (rolling side to side, scooting in bed) with no assistance. Pt is able to get out of bed with assistance without using a bed cane. *Her 2/19/18 Repositioning Bar Assessment Screen indicated:-The therapy assessment had not been completed. -The nursing assessment stated she would not use repositioning bars. -The section for notifying maintenance was not filled out. 2. Observation on 03/13/18 at 04:19 p.m. of resident 53 during personal care revealed:*He was laying in his bed. -There were repositioning bars on both sides near the head of his bed. *Certified nursing assistants assisted him with bed mobility and using a total mechanical lift to move him from his bed to his wheelchair. -During the observation he made no attempt to use the repositioning bars to assist with his bed mobility. Review of resident 53's medical record revealed:*His 2/16/18 baseline care plan and 3/13/18 comprehensive care plan had no mention of repositioning bars. *His 3/6/18 Repositioning Bar Assessment/Screen indicated:-The therapy assessment recommended repositioning bars. -The nursing assessment stated he would not use repositioning bars. -On 3/6/18 at 1:00 p.m. maintenance was notified by work order. Interview on 03/15/18 at 08:44 a.m. with licensed practical nurse A regarding resident 53 revealed:*She thought he might use the repositioning bars to assist wit… | 2020-09-01 |
| 47 | 47 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 740 | G | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the provider failed to ensure four of six sampled residents (17, 21, 42, and 58) who exhibited symptoms of mental health instability had been assessed, monitored, and evaluated in a timely manner to ensure their psychosocial well-being. Findings include: 1. Observations, interviews, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 17 revealed his mental health had been unstable with inappropriate behaviors exhibited towards other residents and staff. Those behaviors had created the potential for mental and physical harm towards them and himself. Refer to F550 and F600. 2. Review of resident 21's 11/18/17 revised care plan revealed: *Focus area: I have specific activity preferences. -Goal for that focus area: My activity preferences will be honored when ever possible during my stay in this facility with current interventions through the next review date. -Interventions for that focus area: --Activity staff will provide me with tools to knit or crochet. It is one of my favorite activities. --I enjoy listening to a variety of country music. Invite me to participate in musical activities. --I enjoy reading. I have a subscription to Readers Digest. I will need my glasses when I choose to read. --I have a TV in my room and enjoy the following programs: Wheel of Fortune, Jeopardy, and Dancing with the Stars. --My religion of choice is Catholic. Remind me when rosary is taking place. *She had a focus area regarding her depression and mood. -That focus area did not support: --Her tendency to self-isolate. --The loss of her two children to ensure staff support through her grieving process had occurred. --Her history and involvement with grief counseling prior to her admission. *The staff had not implemented her care plan to support: -Her activity preferences and requests. -A focus area for her grief over the loss of her children. … | 2020-09-01 |
| 48 | 48 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 745 | E | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and job description review, the provider failed to ensure appropriate social services involvement for six of eight residents (17, 21, 42, 49, 53, and 58) who had mental health concerns to potentially maintain their psychosocial well-being. Findings include: 1. Observation, interview, and review of residents 17, 21, 42, 49, 53, and 58's medical records during the survey revealed a lack of social services involvement related to concerns with abusive situations, incidents and investigations, behaviors, grief support, and suicidal ideation follow-up. Refer to F550, F600, F609, F610, F740, and F758. Interview on 3/27/18 at 5:25 p.m. with the director of nursing (DON) and DON support person B regarding social services revealed she: *Agreed social services coordinator (SSC) S should have been more involved with all the residents who had concerns of mental health instability and behavioral concerns. *Had not been able to identify when SSC S involvement regarding those concerns had changed. *Had not specified what her expectations from SSC S were. *Stated: -Honestly the process just got broken for them. -I did not go back and check to make sure everything was in place for them as I should have. -I learned of the concerns through SS. Interview on 3/28/18 at 8:05 a.m. with the SSC S revealed she: *Agreed: -As a SSC and resident representative she should have been involved with all the residents and their mental health concerns as delineated in her job description. -She should have had the opportunity to facilitate for the residents and families for mental health and behavioral concerns. -As a SSC her role is vital in ensuring: --Those services are carried through for the mental health well-being of the residents. --The families of those residents are comfortable and kept informed of what is in place for their loved one. *Had been involved in completing assessments, monitoring, and documenting on the resi… | 2020-09-01 |
| 49 | 49 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 758 | G | 0 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, policy review, and manufacturers' instructions review, the provider failed to ensure one of five sampled residents (42) who had been given [MEDICATION NAME] (anti-anxiety) and [MEDICATION NAME] (anti-psychotic) on several occasions had documentation to support those [MEDICAL CONDITION] medications had been administered appropriately. Findings include: 1. Observation on 3/12/18 at 4:30 p.m. during the initial tour of resident 42 revealed: *He had a cut over his right eye with steri-strips and bruising. *He had multiple bruises, small scabbed areas, and skin tears on both arms. *Both hands had small open areas. *He was in a wheelchair and mumbled his words when spoken to. Review of resident 42's undated social services assessment by social services coordinator (SSC) S revealed: *He was cognitively impaired. *Behaviors were none known. *He was able to communicate his needs. Review of resident 42's medical record revealed: *He was admitted on [DATE]. *He was not orientated to person, place, or time. *He had [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dementia. -[MEDICAL CONDITION] associated with current urinary tract infection. --He had improved mental status with antibiotic therapy and fluid hydration. -Weakness. *He lived at home with his wife prior and was no longer able to be cared for at home. *He had a [MEDICATION NAME] due to his history of [MEDICAL CONDITION]. *On 2/28/18 the consultant pharmacist had recommended a follow-up Abnormal Involuntary Movement Scale (AIMS) test due to all the [MEDICAL CONDITION] medications that had been initiated and discontinued since his admission. Review of a letter from his wife dated 2/4/18 to the staff at the nursing home revealed: *She said her husband would see things at home, but it was children playing or trains going by. *He was afraid to go outside, because he would get beat up. *He would carry the sugar bowl around looking for a girl that wanted su… | 2020-09-01 |
| 50 | 50 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 842 | F | 0 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to: *Ensure 12 of 13 sampled residents (3, 5, 17, 21, 33, 41, 42, 47, 49, 53, 57, and 58) had complete documentation in their medical records. *Have residents' medical records readily accessible during the survey in a timely manner. Findings include: 1. Review of resident 3's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after four identified falls. Refer to F610, finding 1. 2. Review of resident 5's medical record revealed incomplete or missing documentation related to:*Her falls and interventions implemented related to them. Refer to F610, finding 8. Refer to F689, finding 2 under base statement B. 3. Review of resident 17's medical record revealed incomplete or missing documentation related to: *His behaviors and follow-up to them. Refer to F550, findings 1 and 3. Refer to F600, findings 1, 5, and 7. Refer to F609, finding 4. Refer to F610, finding 6. 4. Review of resident 21's medical record revealed incomplete or missing documentation related to: *Her mental health and grief. Refer to F740, finding 2. 5. Review of resident 33's medical record revealed incomplete or missing documentation related to: *Follow-up and investigation after two identified falls. Refer to F610, finding 2. Refer to F657, finding 5. 6. Review of resident 41's medical record revealed incomplete or missing documentation related to: *Details surrounding her multiple falls and interventions. *Her pressure injuries. Refer to F610, finding 10. Refer to F686, finding 1. Refer to F689, finding 1 under base statement B. 7. Review of resident 42's medical record revealed incomplete or missing documentation related to: *His behaviors and the reason [MEDICAL CONDITION] medications had been given. *Details surrounding his falls and investigations into them. Refer to F610, finding 13. Refer to F758, finding 1. 8. Review of resident 47's me… | 2020-09-01 |
| 51 | 51 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 867 | J | 0 | 1 | CZRE11 | Based on interview and plan review, the provider failed to ensure an effective quality assurance performance improvement (QAPI) program had been implemented and followed through to develop and implement corrective actions for all residents. Findings include: 1. Interview on 03/28/18 at 1:30 p.m. with the administrator, Minimum Data Set (MDS) assessment coordinator, and registered nurse (RN) [NAME] revealed: *They tried to have monthly QAPI meetings. *The committee included the leadership team. *The medical director attended at least quarterly. *They used various methods and information to select actions of the QAPI committee: -Past surveys. -CASPER and quality measure (QM) reports. -They always reviewed certain things such as infection control, falls, and pressure injuries. --For pressure injuries they discussed rates in general. *The QAPI committee started a performance improvement project (PIP) for specific focus areas they were working on. *The current PIPs were for call lights and medication destruction. -Call lights was a concern that was brought up by the residents in their council meeting. -Medication destruction was an area the director of nursing (DON) thought still needed some work. *There had been quite a few changes in the leadership roles in the facility. *The administrator had started in his role in (MONTH) (YEAR). *The DON had started her role in (MONTH) (YEAR). *The MDS nurse was also new to her role within the last year. *RN [NAME] would be learning more about QAPI and being more involved in the future. Continued interview and record review of the attendance sheets for the QAPI meetings from (MONTH) (YEAR) through 3/28/18 revealed: *The administrator stated he was unable to find several of the attendance sheets. -When the new administration took over things changed. -For some reason they stopped keeping track of the attendees. *Their last list of attendees prior to the (MONTH) (YEAR) meeting was on 8/22/17. *The administrator stated they had a meeting in (MONTH) (YEAR), but there was no record of… | 2020-09-01 |
| 52 | 52 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-09-13 | 610 | D | 0 | 1 | YYKW11 | Based on observation, record review, interview, and policy review, the provider failed to ensure two of two sampled residents (13 and 47) with incidents resulting in major injury were fully investigated and reported to the South Dakota Department of Health (SD DOH). Findings include: 1. Observation and interview on 9/11/18 at 10:30 a.m. of resident 13 revealed: *She used a wheelchair for locomotion. *She wore a Cam boot on her left foot. *She reported she had broken her foot when she had fallen from a bath chair a while ago. Review of resident 13's 6/13/18 nursing progress notes revealed: Bath aide requesting help to transfer resident off bath chair into w/c (wheelchair) assist x2 (of two) to stand while assist x1 (of one) to wipe bottom et pull up brief et pants; resident not cooperating; not letting go of sides of the bath chair; resident pulling on staff that was to be wiping et pulling up pants; too much time on lower extremities et resident started going down; resident was lowered slowly to the floor onto her knees; resident c/o (complained of) pain/discomfort to feet. Observation of resident 13 on 9/12/18 at 8:30 a.m. and of one unidentified traveling certified nursing assistant (CNA) and CNA B revealed: *They used a Hoyer lift to transfer her. *CNA B acknowledged the resident had slid from the shower chair about a month earlier. -That had resulted in her fracturing her left foot. *At the time of the fall the aides were attempting to position her in the new bath chair. -They could not get her far enough back in the chair, because it did not fit her correctly. -Also due to the design of the bath chair only one aide could reach the resident, because there was a bar that came down. --That prevented the staff from pulling the resident far enough back. -CNA B had not been working the day she fell . -It had been reported to them afterwards though they should not use the bath with that resident anymore. --They needed to give her a shower. Further observation and interview with CNA B on 9/12/18 at 11:29 a.m. of the… | 2020-09-01 |
| 53 | 53 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-09-13 | 661 | D | 0 | 1 | YYKW11 | Based on record review and interview, the provider failed to ensure one of one sampled resident (54) who was discharged home had a completed discharge summary. Findings include: 1. Review of resident 54's Discharge Summary revealed: *She had been discharged to home on 6/24/18. *A brief nursing summary had been written. *The document asked for a brief therapy, social services, activity, and dietary narrative summary. *All those areas had been left blank. Interview on 9/13/18 at 10:19 a.m. with the director of nurses regarding the above for resident 54 revealed: *When a resident was discharged she sent a request to the appropriate disciplines to complete the Discharge Summary. *It was her expectation for them to complete that document. -That had not been done for the resident. *A request for the policy on discharge summaries was made at that time. -None was received by the end of the survey. | 2020-09-01 |
| 54 | 54 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-09-13 | 692 | D | 0 | 1 | YYKW11 | **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 one sampled resident (50) who was on Hospice services had an appropriate and timely assessment to ensure nutritional parameters were maintained. Findings include: 1. Observation on 9/11/18 at 11:30 a.m. of resident 50 revealed: *He ate at an assisted table during the noon meal. *His daughter was feeding him. Review of resident 50's 9/11/18 physician's orders [REDACTED].>*He was receiving Hospice services since his admission on 6/26/18. *His [DIAGNOSES REDACTED]. *He was on a regular diet with pureed texture. Review of resident 50's weights revealed: *On 6/26/18 he weighed 183.5 pounds (lb). *On 7/6/18 he weighed 177.9 lb. *No further weights had been obtained. Review of resident 50's 7/10/18 dietary progress note revealed: *Weight 7/6/18 176.5 lb. Weight on admission 183.5 lbs. Decrease of 7 lbs. 3.8% decrease. Diet is regular. Resident dines with supervision at meals. Intake at meals 2 breakfast refusals, averaging 75% at meals. BMI (Body Mass Index) = 27.6. %IBW (Ideal Body Weight) 119. *Resident has open areas on left side from tumors. Resident is on Hospice. Written by registered dietitian (RD). *There were no further dietary assessments. Review of resident 50's 7/20/28 care plan revealed: *Focus: I have nutritional problem r/t (related to) [DIAGNOSES REDACTED]. *Goal I will maintain adequate nutritional intake to support weight maintenance by participating in 3 meals a day. *Interventions addressed: a calm environment, inviting to activities that promoted additional intake, and serving the diet that was ordered by the physician. Interview on 9/12/18 at 3:18 p.m. with the consulting registered dietitian and the dietary services manager regarding resident 50 revealed: *He was on Hospice that meant he received palliative care. *They confirmed there had not been a weight on him for over two months. -They could not say for sure why that had… | 2020-09-01 |
| 55 | 55 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-09-13 | 740 | E | 0 | 1 | YYKW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure two of three sampled residents (12 and 41) who exhibited symptoms of mental health instability had been assessed and evaluated in a timely manner to ensure their psychosocial well-being. Findings include: 1. Random observations on 9/11/18 from 7:15 a.m. through 10:29 a.m. of resident 12 revealed he had: *Been sitting in a wheelchair (w/c) either in the hallway or inside of his room. *Been able to propel himself up and down the hallway. *Made non-sensical statements or would repeat what the surveyor stated when he was approached and attempted to visit with. Interview on 9/11/18 at 10:29 a.m. with certified nursing assistant (CNA) A regarding resident 12 revealed he had: *Been confused and alert to self only and was not interviewable. *A history of inappropriate behaviors towards staff and other residents. -Those behaviors had recently increased due to a change in his medications and acquiring a urinary tract infection [MEDICAL CONDITION]. Review of resident 12's medical record from 3/1/18 through 9/12/18 revealed: *An admission date of [DATE]. *His [DIAGNOSES REDACTED]. *He had: -Required staff assistance to ensure all of his activities of daily living were met. -Required the use of anti-psychotic, anti-depressant, and hormonal medications to help with stabilizing his mood and behaviors. -Experienced an exacerbation in his behaviors when the physician attempted to decrease his anti-psychotic medication in (MONTH) (YEAR). --Those increased behaviors included: inappropriate advances and touching of female residents and staff; exit seeking behaviors with successful elopements out of the facility while attempting to locate his wife; hitting, kicking, and a decreased safety awareness which had resulted in several falls. -Required one-on-one monitoring by the staff during those periods of increased agitation and inappropriate behaviors. -Acquired a UTI and had required… | 2020-09-01 |
| 56 | 56 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-09-13 | 849 | D | 0 | 1 | YYKW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and hospice agreement review, the provider failed to ensure one of one sampled resident (50) who received Hospice services had Hospice integrated into the resident's care plan. Findings include: 1. Review of resident 50's 7/9/18 Minimum Data Set (MDS) assessment revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He received hospice services. Review of resident 50's 7/16/18 care plan revealed: *Focus: He had end stage adult T cell [MEDICAL CONDITION]. He was weak and confused and was on Hospice. -Interventions addressed all activities of daily living (ADL) that were to have been provided by facility staff. *Focus: I have end [MEDICAL CONDITION]. I have tumors/[MEDICAL CONDITION] on my left rib cage. I am at risk for pain r/t (related to) this issue and end of life. I am on Hospice services. -Interventions addressed all medications to have been administered by the facility nurses. --There were no interventions addressing how Hospice was utilized in pain management. *Focus: I have a psychosocial well-being problem r/t distractibility/inability to concentrate. End stage disease. -There were no interventions addressing how they would utilize Hospice in addressing psychosocial needs. Interview on 9/13/18 at 10:00 a.m. with the MDS coordinator revealed the care plan did not address what Hospice services was providing. Review of the provider's undated Comprehensive Care Plan policy revealed: *An interdisciplinary comprehensive care plan that includes measurable objectives, goals and timetables to meet the resident's needs is developed by the Interdisciplinary Team (IDT) for each resident and reflects the resident's current status. Accurate and timely care planning is the roadmap for provision of quality care. *It did not address Hospice specifically. Review of the undated Hospice Service Agreement revealed: *Cooperation with Hospice Staff. Center shall cooperate with Hospice staff members in carr… | 2020-09-01 |
| 57 | 57 | WESTHILLS VILLAGE HEALTH CARE FACILITY | 435033 | 255 TEXAS ST | RAPID CITY | SD | 57701 | 2017-06-14 | 241 | E | 0 | 1 | WA4911 | Based on observation, interview, policy review, and quality assurance performance improvement (QAPI) review, the provider failed to: *Create a positive and respectful dining experience for 6 of 14 residents (3, 5, 7, 8, 9 and 16) during two of two observed meals in one of two dining rooms (assisted). *Ensure staff provided assistance with eating in a dignified manner for two of two randomly observed residents (9 and 15). *Ensure one of one randomly sampled resident (17) had not received medication in a public area. *Ensure staff answered call lights in a respectable and and followed up in a timely manner. Findings include: 1a. Observation on 6/13/17 from 10:30 am. through 11:25 a.m. of the assisted dining room (ADR) during brunch revealed: *Residents 15 and 16 had already received their meals and were being assisted by certified nursing assistant (CNA) B. *Resident 9 had been served her meal at 10:30 a.m. and resident 8's meal had been served at 10:45 a.m. *At 11:05 a.m. CNA B left the table with residents 15 and 16 and cued resident 9 to eat her meal. *She then put a bite of food on the fork and cued resident 8 to eat. *She did not sit down with the residents during that time. *She went back and while standing helped resident 15 to take another bite of her food. *She was the only staff member in the assisted dining room until 11:00 a.m. *Three other unidentified CNAs then came into the dining room and assisted residents 3, 5, 7, 8, and 9 with their meal. *Resident 8 and 9's meal had not been reheated. *Resident 14 had received her meal at 10:55 a.m. and her table mate, resident 7, had not received her food until 11:10 a.m. Surveyor: b. Observation on 6/13/17 from 4:40 p.m. to 5:30 p.m. of the main dining room (MDR) and in the ADR revealed: *Five staff consisting of food service and CNAs were available to serve eighteen residents in the MDR. *CNA B was the only available staff to serve and assist fourteen residents in the ADR. She tried to serve, assist, cue, and redirect all fourteen residents during the meal. *… | 2020-09-01 |
| 58 | 58 | WESTHILLS VILLAGE HEALTH CARE FACILITY | 435033 | 255 TEXAS ST | RAPID CITY | SD | 57701 | 2017-06-14 | 281 | D | 0 | 1 | WA4911 | Based on record review, observation, interview, and policy review, the provider failed to follow professional standards for administration of medications by one of one observed licensed practical nurse (LPN) (D) for one of one sampled resident (6) who received medication per an enteral tube. Findings include: 1. Observation on 6/13/17 at 9:20 a.m. of LPN D while she administered medications to resident 6 revealed she: *Prepared the medications for the resident referring to the medication administration record. *She crushed them and mixed them with water individually. *Took those medications and 150 cubic centimeter (cc) of water to the resident's room. *Instilled the medications through the resident's enteral tube. *Flushed the enteral tube with water between each medication administered. *Flushed the enteral tube with a 150 cc bolus of water after the last medication had been administered. Interview on 6/13/17 at 11:00 a.m. with LPN D regarding resident 6 confirmed she had not verified placement of the enteral tube. She had not used a stethoscope to listen before administering his medications. She stated she confirmed tube placement before administering nourishment but not for medications. Interview on 6/13/17 at 11:45 a.m. with the administrator and the director of nurses confirmed the enteral tube placement should have been verified. It should have been done before the resident's medications and water had been administer into that tube. Review of the provider's (MONTH) (YEAR) Enteral Tubes Administration of Formula, Medications, and Liquids policy and procedure revealed placement of the enteral tube was to have been verified With auscultation using 150 cc of air. | 2020-09-01 |
| 59 | 59 | WESTHILLS VILLAGE HEALTH CARE FACILITY | 435033 | 255 TEXAS ST | RAPID CITY | SD | 57701 | 2019-10-09 | 658 | D | 0 | 1 | G9N411 | **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 of one unlicensed assistive personnel (UAP) (A) had supervision of a registered nurse (RN) to ensure the prepackaged medication name received from the pharmacy matched the names on the Medication Administration Record [REDACTED]. *The blood glucose meter had been properly sanitized according to policy by one of one observed UAP (A). *There was a documentated rationale and specified duration for a PRN (as needed) [MEDICAL CONDITION] medication for one of four sampled residents (4) whose medical record was reviewed for unnecessary [MEDICAL CONDITION] medications and medication regimen review. Findings include: 1a. Observation on 10/9/19 at 8:04 a.m. of UAP A while she administered medications to resident 10 revealed the resident's packets of medications stated: *Sentry Senior take 1 tablet orally daily in the morning. *[MEDICATION NAME] 500 MG (milligrams) Take (2) tablets orally twice daily for pain. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. b. Observation on 10/9/19 at 8:45 a.m. of UAP A while she administered medications to resident 15 revealed the resident's packets of medications stated: *Fiber-Lax Take 1 tablet by mouth twice a day.*Thera M Take 1 tablet by mouth every morning. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. c. Interview on 10/9/19 at 8:55 a.m. with UAP A regarding the above for residents 10 and 15 revealed: *UAP A stated she: -Just knew Sentry Senior was the same as [MEDICATION NAME] Silver and [MEDICATION NAME] was the same as [MEDICATION NAME]. -Just knew Thera M was the same as a multivitamin and Fiber-Lax was the same as calcium polycarbophil 625 mg tablet twice a day. -Knew by process of elimination, because she poured all the residents other medicatio… | 2020-09-01 |
| 60 | 60 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2018-05-16 | 610 | D | 0 | 1 | 4XMM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on observation, interview, and record review, the provider failed to complete and fully investigate a staff-to-resident incident for one of one sampled resident (33) who had complaints of severe pain after a facility acquired injury had occurred. Findings include: 1. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her need… | 2020-09-01 |
| 61 | 61 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2018-05-16 | 686 | G | 0 | 1 | 4XMM11 | **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 (44) who required staff assistance with care had not developed a facility acquired pressure injury. Findings include: 1. Observation on 5/15/18 at 8:30 a.m. of resident 44 revealed she: *Had been: -In the dining room eating her breakfast. -Sitting in a Broda wheelchair (w/c) with pressure relieving boots on both of her feet. -Wearing a specialty brace that started at her neck and extended down to her waist. -Able to move her arms without difficulty, but no spontaneous movement of her legs was noted. -Complaining of discomfort and requested an unidentified staff member to take her back to her room. *Appeared weak, frail, and her hair was unkempt. Observation and interview on 4/15/18 at 8:45 a.m. with resident 44 revealed: *She had been: -In her room and sitting in her Broda w/c. -Alert with some confusion to date and time. -Listening to country music on her television and watching the activities going on outside of her window. *She: -Had just received some pain medication and was feeling better. -Continued to wear the speciality brace and pressure relieving boots to both of her feet. -Was not able to remember why she had to wear a specialty brace or boots to both of her feet. *Her: -Feet had been resting on the footrest of the w/c. -Left foot and leg were slightly turned inward. Interview on 5/15/18 at 9:10 a.m. with licensed practical nurse (LPN) J regarding resident 44 revealed: *She had: -Been recently admitted with a compression fracture in her back. -Required the use of a specialty brace for safety and support while the fracture healed. -A wound located on her left heel. -Acquired that pressure injury while she had been receiving care and services in the facility. *LPN J stated She has a black area on her left heel. *The surveyor had: -Informed LPN J and certified nursing assistant (CNA) B she would like to watch th… | 2020-09-01 |
| 62 | 62 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2018-05-16 | 697 | D | 0 | 1 | 4XMM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Based on observation, interview, and record review, the provider failed to ensure adequate pain control was monitored, reviewed, and appropriate interventions were implemented for one of one sampled resident (33) who had complaints of increased pain after a facility acquired injury occurred. Findings include: 1. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impair… | 2020-09-01 |
| 63 | 63 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2018-05-16 | 710 | D | 0 | 1 | 4XMM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her needs known. *There was no documentation to support the physician had been notified of: -The incident and injury that had occurred to the resident's left leg on 5/12/18. -The resident's complaints of increased pain and discomfort -The ineffectiveness of the pain medications the staff … | 2020-09-01 |
| 64 | 64 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2018-05-16 | 880 | E | 0 | 1 | 4XMM11 | Based on observation, interview, and policy review, the provider failed to ensure infection control practices and protocols were followed when providing: *Personal care for two of seven sampled residents (44 and 52) by two of two certified nursing assistants (CNA) (A and B). *Foley catheter care for one of one sampled resident (4) by one of one CNA (A). Findings include: 1. Observation on 5/15/18 at 11:48 a.m. of CNAs A and B during personal care for resident 52 revealed: *He had been laying in his bed and was ready to get up for dinner. *They had sanitized their hands and put on a clean pair of gloves. *With those gloves on they had: -Pushed a mechanical transfer lift over to his bed. -Adjusted his covers and clothes to expose his upper and lower body. -Removed his soiled incontinent brief. *CNA B had: -Assisted the resident to lay on his right side. -Retrieved and opened a package of wet wipes. -Taken several wet wipes out of the package and cleansed his bottom with them. --He had been incontinent with a small amount of bowel movement. -Not removed her soiled gloves and washed/sanitized her hands after performing perineal care for the resident. *CNA A had: -Opened the top drawer of his bedside stand and removed a tube of barrier cream and bottle of powder. -Taken a small amount of barrier cream from the tube and applied it to his bottom. -Opened the bottle of powder and sprinkled some on his bottom over the barrier cream. -Removed her gloves and without washing/sanitizing her hands put on a clean pair of gloves. *With those gloves on they had: -Put a clean incontinent brief on the resident. -Placed a sling underneath of him, pulled the mechanical lift closer to the bed, and attached it to the sling. *They both had assisted the resident out of his bed and into his wheelchair with use of the mechanical lift. *At that time they both removed their soiled gloves and washed their hands. 2. Observation on 5/15/18 at 1:30 p.m. of CNAs A and B during personal care for resident 44 revealed: *The resident had been sitting… | 2020-09-01 |
| 65 | 65 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 166 | E | 0 | 1 | 43OZ11 | Based on interview, record review, and grievance process review, the provider failed to ensure resident council concerns were followed-up on and resolutions were taken back to the resident council. Findings include: 1. Interview on 5/23/17 at 10:00 a.m. with a group of residents revealed: *They had concerns with chicken being served all the time. *The men's bathroom on first floor was not handicap accessible. -The women's bathroom had not been turned into a unisex bathroom. *Laundry items went missing and were not returned. *One resident was still missing an honor flight shirt. *Those concerns had been brought up at resident council meetings. Review of the resident council minutes from 11/28/16 through 4/24/17 revealed: *On 11/28/16 under other business was problems with getting laundry back. -On 12/29/16 under other business it stated Laundry knows they are working on it. -On 1/26/17 there had been no further documentation on the laundry concern. *On 2/27/17 they had requested less chicken. -There had been no further documentation on the laundry concern. *On 3/27/17 they had requested less chicken and stated the men's bathroom on first floor was not accessible. -Two grievance forms had been completed. --The first grievance form had been about having too much chicken. ---The resolution had stated they acknowledged chicken was on the menu way to close together and frequently. ---They would look at menus and change to summer cycle 6/1/17. ---There had been no signatures regarding who had filled out the form. --The second grievance form had been about the men's bathroom. ---The resolution had been to use the women's bathroom, and the sign would be changed to unisex. ---There had been no signatures regarding who had filled out the form. *On 4/24/17 there had been no documentation regarding the follow-up to the menus or the men's bathroom. Surveyor: Interview on 5/24/17 at 8:44 a.m. with the social worker regarding missing clothing items revealed: *Residents were to tell the nursing staff who in turn were to tell the … | 2020-09-01 |
| 66 | 66 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 280 | E | 0 | 1 | 43OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to update care plans to reflect the current needs for 5 of 13 sampled residents (6, 7, 9, 10, and 13). Findings include: 1. Review of resident 9's complete medical record revealed: *He was admitted on [DATE]. *He received blood thinning medication. *He had [DIAGNOSES REDACTED]. *No skin diagram and progress note was found in the skin documentation book. Review of resident 9's 5/16/17 wound care nurse's recommendations revealed: *Zinc oxide paste currently being used seems to have difficulty adhering to the open sores of the sacral area. *[MEDICATION NAME] paste to be used in place of zinc oxide. A thick layer should be placed several times a day and with every incontinent episode. *Cleanse the top layer of the [MEDICATION NAME] but do not attempt to clean off all of the [MEDICATION NAME] prior to every re-application. *An alternating low air loss mattress. *A pressure redistribution cushion to his wheelchair. *Resident to be up to the chair for meals and therapy, otherwise in bed to relieve pressure off his sacrum. *Frequent repositioning is also necessary as he is quite immobile. *Heel lifts are in place to bilateral feet. *Pillows to be used to off-load pressure from the heels and for repositioning, at least every two hours, with micro turns in between. Review of resident 9's 5/11/17 care plan revealed: *A problem area of Skin integrity. *A goal of Skin integrity - improve. *The following interventions: -Heel protectors at all times. -[NAME] hose should be on during the day and removed at night. -Pressure redistributing cushion in chair. -Pressure redistributing mattress. -[MEDICATION NAME] is to be reapplied with every incontinent episode - thickly so that covers the complete area that is open. Foaming wash needs to be used to cleanse buttock - do not scrub the [MEDICATION NAME] off. -Monitor deep tissue injury to sacrum area daily until healed. -Braden … | 2020-09-01 |
| 67 | 67 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 284 | D | 0 | 1 | 43OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to implement discharge planning for one of one sampled resident (10) who was independent and wanted to move to an assisted living center. Findings include: 1. Observation and interview on 5/23/17 at 11:00 a.m. with resident 10 revealed: *She walked without a walker or assistive device. *She was well groomed. *She stated she gave herself her own shower. *She wanted to move into an assisted living center. *She had a microwave in her room, and they had taken it away from her. -She wanted the microwave back. *She liked to play cards. *She liked to walk. Surveyor: Observation and interview on 5/23/17 at 11:24 a.m. with resident 10 revealed: *Licensed practical nurse (LPN) F had taken her blood glucose and it had been 113. *LPN F had asked her if she wanted her noon dose of insulin. *Resident 10 replied she did not need her noon dose of insulin. *LPN F explained that resident 10 makes her own decisions if she wants her insulin according to her blood sugars. Surveyor: Review of resident 10's 1/26/17 care plan revealed there were no goals or interventions for discharge planning. Review of resident 10's medical record revealed she was her own power of attorney and made her own decisions. She had been admitted on [DATE]. Review of resident 10's 9/28/16 and 1/6/17 social services notes revealed: *She had stated her desire to move out of the facility and into the community. *There had been no documentation regarding discharge planning that had occurred following those requests. *On 1/6/17 Section Q she really wanted to return to the community but her family think it isn't feasible at this time due to meds and diabetes. Review of resident 10's 10/19/16 care conference note revealed she wanted to move out. She was interested in the independent living center in Chamberlain. It stated she and her daughter were looking into it. There had been no documentation in regards to … | 2020-09-01 |
| 68 | 68 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 329 | D | 0 | 1 | 43OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to attempt non-pharmacological interventions and have a documented justification for starting an antipsychotic medication for one of one sampled resident (7). Findings include: 1. Random observations on 5/23/17 from 7:55 a.m. through 5:00 p.m. of resident 7 revealed she had been in bed. Surveyor: Interview on 5/23/14 at 2:15 p.m. with resident 7's son revealed: *His mother has been feisty all of her life. -He had not seen a change in his mother's personality concerning her cooperation with staff. *He visited often, as he worked nearby. *She recognized him and had called his name. Surveyor: Review of resident 7's medical record revealed: *She had been admitted on [DATE]. *She had been started on [MEDICATION NAME] on 4/5/17 due to behaviors. *She had been put into hospice care on 4/12/17. -They had requested the [MEDICATION NAME] be discontinued on that date. -The physician had not discontinued it. *On 5/3/17 the [MEDICATION NAME] had been discontinued. Review of resident 7's interdisciplinary notes revealed: *On 3/31/17 Is combative with cares at times. *On 4/1/17 Once she had it in her mouth she put a tissue up to her mouth and removed the medications. 'I am not going to take this[***]' *On 4/2/17 Spit out most of the medication at 1700 and refused hs (bedtime) medications and became very vocal. *On 4/2/17 Found during the night to have gotten up independently and walked across the hall and sit on another residents bed. *On 4/3/17 Angry with the pressure of the BP (blood pressure) cuff and then pushes me away and will not let me continue my assessment. *There had been no other documentation regarding behaviors or what non-pharmacological interventions had been attempted. Review of resident 7's 4/6/17 physician's visit note revealed: *The patient has not voiced complaints, is minimally verbal. *Staff reports that she has become occasionally belligerent in th… | 2020-09-01 |
| 69 | 69 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 371 | E | 0 | 1 | 43OZ11 | Based on observation, interview, and policy review, the provider failed to ensure cleanliness of 3 of 4 refrigeration cooler fans and failed to ensure food sanitation practices were followed when food was being stored in 1 of 1 dry storage areas in the kitchen pantry. Findings include: 1. Observation on 5/22/17 at 4:13 p.m. of 2 of 2 walk-in produce and dairy coolers revealed several opened, undated, and unlabeled food items and several dirty cooler fans had not been maintained in a clean and sanitary manner: *Small container of potato salad. *A bag of lettuce. *A bag of spinach. *One dirty fan cover in the produce cooler was covered with a black fuzzy substance. *Two dirty fan covers in the dairy cooler were covered with a black fuzzy substance. 2. Observation on 5/22/17 at 4:40 p.m. of the dry storage area in the kitchen pantry revealed a large bag of panko bread crumbs was opened. However it was not in a storage container and dated. 3. Interview on 5/23/17 at 10:50 a.m. with the supervisor of food services confirmed: *The following food items should have been labeled and dated. -The container of potato salad. -The bag of lettuce. -The bag of spinach. *Food items should have been stored properly. *Cooler fans should have been on a cleaning schedule. Interview on 5/24/17 at 2:45 p.m. with the director of nursing, registered dietician, dietary manager confirmed: *All opened food that was not in the original container should have been labeled and dated. *All prepared food should have been labeled and dated. *Cooler fans should have been on a routine cleaning schedule. Review of the provider's undated POLICY CLEANING FANS AND CEILING IN WALK IN COOLERS AND FREEZERS revealed: *How to clean the fans. *Did not list the schedule for cleaning. Review of the provider's revised (MONTH) (YEAR) Food Storage policy revealed: *Dry storage foods must be covered and dated if container was opened and partially used. *All foods should have been covered, labeled, and dated with labels on the sides of the containers, if the food wa… | 2020-09-01 |
| 70 | 70 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 441 | E | 0 | 1 | 43OZ11 | Based on observation, interview, record review, and policy review, the provider failed to ensure nebulizer equipment had been cleaned according to the provider's policy for three of three residents (4, 18, and 19) that had received breathing treatments randomly observed. Findings include: 1a. Observation on 5/23/17 at 11:00 a.m. with resident 18 revealed: *The nebulizer equipment was fully assembled with a small amount of clear liquid in the medication chamber. *Medication was added to the medication chamber, without removing the small amount of clear liquid, by licensed practical nurse (LPN) F. b. Observation on 5/24/17 at 7:52 a.m. with resident 19 revealed: *The nebulizer mask and medication chamber was assembled and laying on the bedside stand. *There was a small amount of clear liquid in the chamber, prior to the medication being added to the chamber. *Medication was added by registered nurse (RN) E. c. Observation on 5/24/17 at 11:15 a.m. with resident 4 revealed: *His nebulizer was fully assembled with a small amount of a clear liquid in the medication chamber. *Medication was added to the chamber, without removing the small amount of clear liquid, by LPN F. d. Interview on 5/24/17 at 8:45 a.m. with LPN [NAME] revealed: *The night staff cleaned the nebulizer equipment every three days. *The equipment should have been replaced every month by night staff. -Including mouth piece or mask, medication chamber, and tubing. *These dates were noted on the treatment plan. Interview on 5/24/17 at 3:35 p.m. with the director of nursing (DON) revealed: *She would have expected the chamber and mouth piece or mask to have been disassembled and rinsed after every use. *Then should have been allowed to air-dry on a towel in the resident's room. Interview on 5/25/17 at 2:15 p.m. with CNA G revealed: *She had not seen the nebulizer equipment air drying in residents' rooms. *Usually they were placed on the bedside table fully assembled. Review of resident 4's medication administration record (MAR) revealed to clean the mask a… | 2020-09-01 |
| 71 | 71 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 456 | E | 0 | 1 | 43OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and manufacturer's instructions, the provider failed to ensure: *Two of three whirlpool baths (100 and 300 floors) were maintained in working order, with all jets covered, on a regular basis. *Eight of eight EZ Stand lifts shared and moved between the three floors were maintained on a monthly basis with safety clips/safety tabs in place as per manufacturer's instructions. Findings include: 1. Observation on 5/22/17 from 4:25 p.m. through 5:45 p.m. identified: *Three EZ Stand lifts on the 100 floor had: -Combination metal safety clips and rubber tabs on all three lifts on the floor. -Rubber tabs were not positioned to hold the lift sling loops in place. *The whirlpool tub jets were missing five of twelve inserts and nine of twelve covers. 2. Observation on 5/23/17 at 9:00 a.m. on all three floors found: *A total of eight lifts (100, 200, and 300 floors) had the same above observations as were made on the 100 floor. *The whirlpool tub on the 300 floor was missing seven inserts and ten covers. 3. A group meeting with residents on 5/23/17 at 10:00 a.m. revealed the jets had not been working on the 100 floor whirlpool. 4. Interviews on 5/24/17 between 9:00 a.m. and 9:20 a.m. with certified nursing assistants I and J on the 100 floor revealed the whirlpool jets worked if the tub was half filled with water but not if the tub was full of water. Interview on 5/24/17 at 10:40 a.m. with the maintenance staff person H revealed: *He believed biomedical engineering was maintaining the lifts. -After calling biomedical engineering it was found they only maintained the electrical components not the lift itself. *There was no routine or preventative maintenance of the lifts being done. *He had not been informed of the whirlpool tub jets on the 100 and 300 floors missing inserts and covers. -Nursing staff were to notify the maintenance department. *He had not been informed of the whirlpool jets not working on the 100 floor. -Nur… | 2020-09-01 |
| 72 | 72 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2019-08-07 | 550 | D | 0 | 1 | ILL611 | Based on observation, interview, record review, and review of the Resident Information Handbook, the provider failed to ensure one of one sampled resident (52) was dressed in a dignified manner. Findings include: 1. Observation on 8/5/19 at 5:45 p.m. of certified nurse aide (CNA) G and CNA H revealed: *They had transferred resident 52 with a mechanical lift. *The backside of the resident's pants had been cut from the center of the waistband to the crotch. *CNA G had stated that made it easier to remove the resident's pants when she was toileted. *CNA G had given the resident two plastic clips to secure her shirt to the pants after the lift was completed. Interview on 8/5/19 at 5:52 p.m. with resident 52 regarding those pants revealed: *She had stated I hate it. *The modified pants made her feel self-conscious. *She said staff had told her they were working on a modification to make the cut pants more discreet. -She had been told that over a month ago. Interview on 8/6/19 at 2:15 p.m. with resident 52 revealed: *She had gone into the community today and had been dressed in a regular pair of pants. *She was re-dressed upon returning to the facility into a pair of cut pants. -The cut pants were not her own and had been provided to her by the facility. *She had stated They (the pants) keep falling down. -The plastic clothespin and another plastic clip she had used to keep her pants up were her own. Interview on 8/7/19 at 1:20 p.m. with the social services designee revealed: *She was aware of resident 52's dislike of the cut pants. -That had been discussed at her 7/3/19 interdisciplinary care conference. -She had thought a staff member was working on a modification to the pants. *She was unaware the resident had been using her own plastic clothespin and clip to secure her top to her pants. -She had thought the clothespin and clip were appropriate to use if it works. *She was unaware of the resident's concern for skin exposure when she wore the cut pants. -She had stated I don't know if it looks so good dignity wise an… | 2020-09-01 |
| 73 | 73 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2019-08-07 | 656 | D | 0 | 1 | ILL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to develop and revise individual care plans to reflect the current needs for 2 of 14 sampled residents (3 and 31). Findings include: 1. Multiple random observations on 8/6/19 from 9:00 a.m. through 5:30 p.m. and again on 8/7/19 from 8:30 a.m. through 2:00 p.m. of resident 3 revealed he: *Sat in his slightly reclined Broda chair. *Had pink foam boots on both heels. *While he sat with the pink foam heel protectors on his heels had been firmly pressed against his chair. That would have offered no pressure relief or off loading for his heels. *Both of his legs were contracted. *There had been no protection for his lower legs and knees for pressure relief. Review of resident 3's revised 8/2/19 care plan revealed: *A problem area stated: Skin integrity. -The goal for the above focus area regarding the resident's heels and legs had been: Maintain. -Interventions for the above had been: --Heel protectors on while in bed and/or offload heels on pillows. --Place cushion/pillow between knees to provide protection from his knees pressing on each other. Interview on 8/7/19 at 4:00 p.m. with the administrator and director of nursing regarding resident 3 revealed they: *Confirmed the resident had a right heel pressure ulcer. *Agreed the pink foam boots did not offer pressure relief when they had been constantly pressed on the foot and leg area of the Broda chair. *Agreed the resident was to have had a cushion and pillow between his knees for preventative pressure relief. Review of the provider's last revised (MONTH) (YEAR) Pressure Ulcer Prevention and Wound Treatment policy revealed its purpose had been: *To improve resident safety by identifying individuals at risk for healthcare-acquired pressure ulcers; to systematically assess and document skin risk factors; to implement skin-protection components of care, and to provide appropriate treatment when indicated. *Interventions will be … | 2020-09-01 |
| 74 | 74 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2019-08-07 | 698 | D | 0 | 1 | ILL611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the provider failed to ensure communication between a [MEDICAL TREATMENT] center and the provider was documented, that nursing staff were assessing the resident for change of condition, and they were following physician orders [REDACTED]. Findings include: 1. Review of resident 31's medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status assessment score of fifteen indicating she was cognitively intact. *Her [DIAGNOSES REDACTED].>-Type two diabetes. -End stage [MEDICAL CONDITION]. -Dependence on [MEDICAL TREATMENT]. -[MEDICAL CONDITION]. -Heart failure. -[MEDICAL CONDITION]. *She had been receiving [MEDICAL TREATMENT] three times per week. *She had an arteriovenous (AV) fistula place on 7/31/19. *[MEDICAL TREATMENT] post-assessment had not been completed since 7/18/19. Review of resident 31's 7/31/19 nurses note revealed: *She had returned from an appointment for the AV fistula placement. *The dressing was to be removed after forty-eight hours. *She was to do stress ball exercises twenty times every hour while awake. Review of resident 31's last reviewed 6/27/18 care plan revealed a [MEDICAL TREATMENT] post assessment was to be completed on [MEDICAL TREATMENT] days. Interview on 8/7/19 at 10:14 a.m. with registered nurse (RN) B regarding resident 31 revealed: *An assessment was to be done in the electronic medical record when she returned from [MEDICAL TREATMENT]. -She did know how to find and complete assessment. -She did not know where the assessment was to review it after it had been completed. *The resident had a fistula placed a couple days ago on 7/31/19. Interview on 8/7/19 at 10:23 a.m. with resident 31 and her husband revealed that they did not know if a post-[MEDICAL TREATMENT] assessment had been done after her [MEDICAL TREATMENT] treatments. Interview on 8/7/19 at 11:40 a.m. with RN A regarding resident 31 revealed the [MEDICAL TREATMENT] post-assessm… | 2020-09-01 |
| 75 | 75 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2019-08-07 | 812 | E | 0 | 1 | ILL611 | Based on observation, record review, and interview, the provider failed to ensure proper sanitation practices including hair net accessibility, hand sink cleaning, dishwasher cleaning, water line maintenance, and temperature probe calibration had occurred in the nursing home dish room and kitchen. Findings include: 1. Observation and interview on 8/6/19 at 11:05 a.m. with dietary staff person F during the dish room tour revealed: a. Hairnets: *There were no hairnets available in the dish room. -Dietary staff person F had stated those who entered the dish room usually were already wearing a hair covering. b. Hand washing sink: *The white porcelain hand washing sink was a dirty off white and yellowish color. *There were small bits of brown debris stuck inside the sink bowl and its perimeter. -The bits could be removed by scraping them with a fingernail. *The sink drain had a two to three inch ring of orange around it. c. Dishwashing machine: *The top of the machine was covered with a raised off white to light brown crusty substance that could not be removed by swiping a finger across it. *Along the back edge of the dishwashing machine were two separate dark brown areas between six and 10 inches in length and approximately three to four inches in width. -The shape of those areas suggested liquid had sat and dried there. -The hardware along that back edge was crusty with what looked like a lime build-up. *On top and to the front of the dishwashing machine were wash, rinse, and final rinse gauges. -There was a thick hard raised black substance that ran a length of about twelve inches in front of those gauges. d. Dishwashing machine cleaning: *Dietary staff person F had stated he de-limed and thoroughly cleaned the dishwashing machine every other weekend. -He had stated there was no dishwashing machine cleaning schedule. -The dishwashing machine vendor came at the end of each month to assess the condition of the dish machine. e. Dishwashing machine water lines: *There were two water lines visible beneath the area where… | 2020-09-01 |
| 76 | 76 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 225 | D | 0 | 1 | X0TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and plan review, the provider failed to thoroughly investigate and have adequate documentation to support findings of an unsubstantiated conclusion of allegations of neglect for two of two sampled residents (1 and 5). Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE] with a [DIAGNOSES REDACTED]. *She was alert, and oriented to person, with periods of confusion. -She was able to state her needs. *She was bedridden due to her obesity and the number of staff it would have required to safely transfer her. Further review of resident 1's medical record revealed: *12/11/16 nurses note It was brought to nurses attention that resident had been on bedpan indefinite time period. Resident had the indentation in the shape of a bedpan pressed into her skin and the indentation was 1/16 to 1/8 deep and red in appearance. Resident states is left on bedpan for hours at a time but no one believes her and generally happens at shift change. The nurse asked all staff from med aides to CNA's (certified nursing assistants) on each hall if they had placed or assisted another staff member on helping place the resident on bedpan anytime between the hours of 5:30 am to 10:45 am on 12/11/16. All staff answered no. -It was also brought to the nurses attention at the time the bedpan was discovered the CNA (name) stated the Foley catheter had not been emptied and contained 1550 ml (milliliter) at 1045 raising the question if it had been emptied at the end of the night shift. *12/12/16 fax sent to the physician: (Resident name) was on the bedpan for an extended period of time on 12/11. *Review of resident 1's 11/02/16 care plan revealed: Resident was at risk for skin breakdown. Staff were to assist me to change position at least every two hours. Review of the initial report/investigation sent to the South Dakota Department of Health (SD DOH) on 12/11/16 for the above incident of resident 1… | 2020-09-01 |
| 77 | 77 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 241 | D | 0 | 1 | X0TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the provider failed to ensure residents' dignity and respect was maintained during the removal of a deceased resident's body for two of nine random residents (8 and 10) as well as the deceased resident. Findings include: 1. Observation on [DATE] from 12:10 p.m. through 12:25 p.m. in the Bistro dining room revealed: *The funeral home van had backed up directly in front of a large window that could be seen from the Bistro dining room. *At 12:10 p.m. the funeral home had entered the front door with an empty cart. -He passed by the Bistro dining room where approximately twenty residents were waiting for lunch. *At 12:25 p.m. the funeral home passed the dining room again with the body of a deceased resident on the cart. *The window blinds were left open. *The loading of the body in the van was visible to the residents in the dining room. *Also an unidentified visitor was coming in the front door at that time. Observation and overheard conversation on [DATE] from 12:10 p.m. through 12:25 p.m. of resident 8's conversation with his table mates revealed he: *Had said to his table mates, I just hate it when he backs up right there and brings that cart in the front door. *Also conversed about: -When the body was taken out past the dining room and into the van, they had not liked that. -They had not liked the way the window was left open, and that was not right. On [DATE] at 3:00 p.m. during the resident group interview revealed resident's 8 and 10 stated: *They did not think the funeral home should remove a deceased resident's body out of the front door during meal time. -It happened frequently during meal time. *They thought it was very disrespectful to the deceased and for the residents in the dining room. Interview on [DATE] at 7:25 a.m. with the director of nursing (DON) and administrator revealed: *They were unaware the above happening would have bothered any residents. *They knew the deceased resident had been … | 2020-09-01 |
| 78 | 78 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 248 | D | 0 | 1 | X0TZ11 | Based on observation, record review, interview, and policy review, the provider failed to ensure activities were individualized for 2 of 13 sampled residents (3 and 13). Findings include: 1. Random observations on 1/31/17 from 9:15 a.m. through 11:50 a.m. of resident 3 revealed she had been in her room sitting in the recliner with her eyes closed. Observation on 1/31/17 from 3:00 p.m. through 3:30 p.m. of resident 3 revealed she was slouched in her wheelchair sitting by the nurses station. There had been no one talking with her. Review of resident 3's 11/24/16 Minimum Data Set assessment revealed: *Her vision was moderately impaired. *Her Brief Interview for Mental Status (BIMS) score was a three. -A score of zero through seven meant her thinking ability was severely impaired. *It was very important for her to: -Have music. -Be around animals. -Keep up with the news. -Participate in group activities. -Do her favorite activities (none listed). -Go outside. -Participate in religious activities. Review of resident 3's current undated care plan revealed: *A focus area: I enjoy some in room activities. -Interventions were: --I watch television in my room/open court/activity room daily. --I enjoy news, movies, game shows, and other desired programs. --Staff assist me to read mail I receive. --Staff provide me with 1:1 (one-to-one) visits PRN (as needed). *A focus area: I enjoy some specific planned activities. -Interventions were: --I am provided with salon services as scheduled/desired. --I attend Christian life services as scheduled on Sunday. --I enjoy attending special events/music when scheduled. --I enjoy nailcare as scheduled/desired. --I enjoy participation in crafts as scheduled. --I enjoy socializing with other residents and staff throughout the day. --My family/friends visit for socialization. --Staff assist me with calling my daughter weekly. --Staff invite/escort me to games as scheduled. --Staff need to anticipate (resident name) needs d/t (due to) her poor vision and she may need help with her activity/c… | 2020-09-01 |
| 79 | 79 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 253 | D | 0 | 1 | X0TZ11 | Based on observation, interview, and manufacturer's instructions, the provider failed to have four of four different types of lifts on a preventative maintenance checklist. Findings include: 1. Random observations from 1/31/17 through 2/1/17 throughout the facility revealed: *There were four different brands and types of lifts in-use. -Arjo. -Invacare. -Medcare. -EZ lift. Interview on 2/1/17 at 1:00 p.m. with the maintenance supervisor and the administrator revealed they had not had any of the lifts on a preventative maintenance program. The certified nursing assistants would bring the lifts to the maintenance area if they were not working. They were unaware of what lifts needed clips and what lifts did not need them. Review of the manufacturer's instructions for the Arjo lifts revealed inspections should have been done monthly. Review of the manufacturer's instructions for the Invacare lifts revealed inspections should have been done monthly. Review of the manufacturer's instructions for the Medcare lifts revealed inspections should have been done daily and periodically. Review of the manufacturer's instructions for the EZ lifts revealed inspections should have been done every six months. | 2020-09-01 |
| 80 | 80 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 280 | D | 0 | 1 | X0TZ11 | Based on observation, record review, interview, and policy review, the provider failed to update and follow care plans for 2 of 13 sampled residents (3 and 13). Findings include: 1. Observation on 1/31/17 at 9:10 a.m. of resident 3 revealed she had been: *In her room sitting half-way off the seat of her wheelchair. -Scooting around her room with her feet. *Attempting to pick clothes up off the recliner and was leaning forward. Interview on 1/31/17 at 9:50 a.m. with the director of nursing (DON) regarding resident 3 revealed she used to use a walker. She had not used a walker since (MONTH) (YEAR). She currently got around in her wheelchair. Observation on 1/31/17 from 11:50 a.m. through 12:35 p.m. of resident 3 revealed: *She had been served her food at 12:20 p.m. *She was served turkey with gravy, round small white potatoes, a bun, and fruit in a separate bowl. *Her neighbor cut up the turkey for her. Review of resident 3's current undated care plan revealed: *She was supposed to have her meat cut-up. *It stated she ambulated with a four wheeled walker. *Resident often refuses to sit in a chair and wants to sit on her walker, she has been educated on safety with her walker, and staff will continue to encourage her to sit in a chair at the table. Interview on 2/1/17 at 2:30 p.m. with the DON, the administrator, and the nurse consultant regarding resident 3 revealed the care plan had not been updated to reflect she was no longer using the walker. They were not aware the dietary staff had not been cutting up her meat but agreed she would not have been able to do it herself. Review of the provider's (MONTH) (YEAR) care planning policy revealed: *Care planning was constantly in process. *Care plans should be updated between care conferences to reflect current care needs. *Any information updated or discontinued in the resident's care plan will include the date of the changes. 2. Observation on 1/31/17 of resident 13 at the 12:00 noon and supper meals revealed he sat at a table by himself. Further observations revealed… | 2020-09-01 |
| 81 | 81 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 283 | D | 0 | 1 | X0TZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure a summary for one of one sampled discharged resident's (15) stay was completed. Findings include: 1. Review of resident 15's medical record revealed he had been admitted on [DATE] and discharged on [DATE]. He had received therapies to recover from hematuria and a urinary tract infection. No summary of his stay was found within that record. Interview on 2/1/17 at 10:30 a.m. with the director of nursing confirmed no discharge summary had been completed on resident 15. She stated one should have been completed since the discharge was anticipated. Review of the provider's (MONTH) (YEAR) Discharge Plan and Summary policy revealed: *The interdisciplinary team would complete the discharge summary on all residents who were discharged . *That summary should have included a recapitulation of the resident's stay including: -Diagnosis. -Course of disorder/treatment or therapy. -Pertinent lab, radiology, and consult reports. -A final summary of the resident's stauts to include items in the comprehensive assessment at the time of discharge. -A post-discharge plan of care. | 2020-09-01 |
| 82 | 82 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 312 | D | 0 | 1 | X0TZ11 | Based on observation, record review, interview, and policy review, the provider failed to ensure assistance with eating was given to one of one sampled resident (3) who had a visual impairment and impaired thinking ability. Findings include: 1. Review of resident 3's 11/24/16 Minimum Data Set assessment revealed: *Her vision was moderately impaired. *Her Brief Interview for Mental Status (BIMS) score was a three. -A score of zero through seven meant her thinking ability was severely impaired. *She was independent with eating, and only needed set-up help. Observation on 1/31/17 from 11:50 a.m. through 12:35 p.m. of resident 3 in the dining room revealed: *She had been served her food at 12:20 p.m. *She was served turkey with gravy, round small white potatoes, a bun, and fruit in a separate bowl. *She was unable to find her silverware. *She used her fingers to pick up the potatoes. *Her neighbor at the table had told her where her silverware were. *She stabbed the whole bun with her fork. *Her neighbor told her not to do that and instructed her to pull the bun apart. *Her neighbor cut up the turkey for her. *At 12:30 p.m. she asked this surveyor what was on her plate and stated she could not see what was on it. *The turkey was pointed out to her, and she still could not see it or pick it up with a fork. *She asked this surveyor where the potatoes were and continued to poke around on her plate until she was shown. Observation on 1/31/17 from 5:25 p.m. through 6:10 p.m. of resident 3 in the dining room revealed: *At 5:45 p.m. she had been served a sandwich, beets in a cup, and soup by the licensed social worker (LSW). *Her neighbor had told her to wake up. *She told the LSW she could not see the food. *The LSW dumped the beets onto her plate with the sandwich. *She used her fork for her soup. *She asked what the sandwich was, and staff told her she could pick it up with her hands. *She then attempted to pick up the bowl of soup. -Staff stopped her before it had spilled. *She asked again what her sandwich was. *She wa… | 2020-09-01 |
| 83 | 83 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 323 | D | 0 | 1 | X0TZ11 | Based on observation, record review, interview, and policy review, the provider failed to complete fall risk assessments, implement interventions, and complete thorough fall investigations for one of one sampled resident (3) who had multiple falls. Findings include: 1. Observation on 1/31/17 at 9:10 a.m. of resident 3 revealed she had been: *In her room sitting half-way off the seat of her wheelchair. *Confused when talking to the medication aide. *Scooting around in her room in her wheelchair with her feet. *Attempting to pick clothes up off the recliner and was leaning forward. Review of resident 3's medical record revealed she had fallen on 1/28/16, 1/29/16, 2/1/16, 3/8/16, 6/3/16, 7/4/16, 10/5/16, 10/7/16, 10/8/16, 10/18/16, 11/2/16, 11/26/16, 12/18/16, and 1/17/17. Review of resident 3's 8/24/16 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was a three. A score of zero through seven meant her thinking ability was severely impaired. Review of resident 3's 11/24/16 MDS assessment revealed her BIMS score was a one. A score of zero through seven meant her thinking ability was severely impaired. Review of resident 3's 5/16/16 Fall Risk assessment revealed: *She had a score of fourteen. -A score of ten or above indicated a risk for falling. *There had not been an (MONTH) (YEAR) or (MONTH) (YEAR) Fall Risk assessment completed. Review of resident 3's 10/5/16 Fall Scene Investigation report revealed: *She had lost her balance while reaching for a piece of paper on the floor. *The re-enactment of the fall section had not been completed. *The fall huddle (What was different this time?) section had not been completed. *There had been no change to the current care plan. Review of resident 3's 10/7/16 Fall Scene Investigation report revealed: *She had lost her balance while reaching for a piece of paper on the floor. *The medications given in last 8 hours section had not been completed. *The re-creation of last 3 hours before fall section had not been completed. *The re-ena… | 2020-09-01 |
| 84 | 84 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2017-02-01 | 441 | D | 0 | 1 | X0TZ11 | Based on interview and policy review, the provider failed to ensure lift slings and lifts were appropriately cleaned between residents on four of four resident wings (100, 200, 300, and 400). Findings include: 1. Interview on 1/31/17 at 11:35 a.m. with certified nursing assistant (CNA) B revealed: *Lift slings were usually stored on the lift and were used for multiple residents. *The lifts should have been wiped off between residents, but that was not always done. *Slings were sent to laundry when visibly soiled. Interview on 2/1/17 at 7:20 a.m. with CNA C revealed: *Lift slings were used for multiple residents. *Slings were sent to laundry only when visibly soiled. *Lifts were not always wiped off between residents use. Interview on 2/1/17 at 7:25 a.m. with the administrator and the director of nursing revealed: *When slings were visibly dirty they would send them to laundry. *Management had talked about getting everyone their own sling. *Lifts were to have been wiped down every night. Review of the (MONTH) (YEAR) Safe Lifting and Moving of a Resident policy revealed residents would have been provided with single-resident use disposable slings. | 2020-09-01 |
| 85 | 85 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 580 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure notification to the physician had occurred with a change in condition for one of two sampled residents (47) who had shortness of breath. Findings include: 1. Interview on 2/27/18 at 2:30 p.m. with resident 47 and her power of attorney (POA) during the resident council meeting revealed: *She had felt short of breath last night (2/26/18) and thought she had an order to have her inhaler more then one time per day. *She asked the nurse when she had gotten her inhaler last and told her she needed it again, but the nurse would not give it to her. *The nurse had told her she did not have an order to have it more then one time per day. *It had made her feel bad that she could not have her inhaler. *The POA stated he had spoken with a staff member today, and they stated they were not able to find the order she could have the inhaler more then one time per day. Review of resident 47's 2/6/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status score was fourteen indicating she had no cognitive impairment. *She had been independent with transfers, walking, and personal hygiene. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Heart failure. -Hypertension. -[MEDICAL CONDITION]. -Arthritis. -[MEDICAL CONDITION]. -Depression. -Asthma. *Section J revealed her health conditions included shortness of breath with exertion. Phone interview on 3/01/18 at 10:30 a.m. with resident 47's POA revealed: *He thought she had an order prior to entering the facility to get the inhaler more then one time per day. *But when she had been admitted to the facility they had switched her physician, and he was not aware of what changes they had made to her medications. *The staff member he had spoken to on 2/27/18 had been the director of nursing (DON). -She could not find the order for an inhaler for more then one time per day. -She had schedul… | 2020-09-01 |
| 86 | 86 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 600 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and policy review, the provider failed to ensure one of one sampled resident (43) who was dependent upon the staff for all activities of daily living (ADL) was not left on a toileting device for an extended period of time resulting in bruising to the skin. Findings include: 1. Record review for resident 43 revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status score was eleven indicating she had moderate impairment. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. *She was dependent upon the staff for all her ADL. Record review of a 2/18/18 incident regarding resident 43. revealed: *CNAs W and V had assisted her onto a bedpan on 2/18/18 at 5:08 p.m. *CNA W did not check back on her. *She was left on the bedpan for over an hour. -Call Light report showed her call light had been on for twenty one minutes prior to being answered at 6:48 p.m. *CNA R had answered her call light and discovered she was on the bedpan. -Resident stated her hip hurt. -Cleaned her up and went to get the nurse. *RN K assessed her and found a 1.5 inch by 6 inch bruise in the shape of the bedpan on her left hip/buttock area. *Resident had been interviewed by RN K and the administrator by phone. -She had not remembered being on the bedpan. -She had not used the call light for assistance off the bedpan. -She had put her call light on when she noticed her hip hurt. *Both CNAs were suspended pending the investigation. -CNA V had returned to work the next day, 2/19/18. -CNA V was educated on the new bedpan use. -CNA W resigned without notice. *Findings were substantiated. *QAPI with immediate education began 2/18/18. Interview on 2/27/18 at 1:00 p.m. with registered nurse (RN) I regarding resident 43 care revealed: *She needed total assistance of two staff with a Hoyer lift for transfers. *She used a bed pan for her bladder and … | 2020-09-01 |
| 87 | 87 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 610 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to thoroughly investigate twenty-four falls for one of five sampled residents (41). Findings include: 1a. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had twenty-four falls since her admission date of [DATE]. -Two of those falls resulted in major injury. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. Review of resident 41's 12/19/17 fall scene investigation reports revealed: *She had been found on the floor of the bathroom at 9:00 p.m. -She crawled out of bed and got to the bathroom. -She urinated on bathroom floor and had a lg (large) round BM (bowel movement) which she was holding in her left hand. -She moved all extremities and tried to crawl back to her bed during assessment. -What appeared to be the root cause of the fall had been Needing to toilet. --At 4:00 a.m. Res (resident) has been caught 6x's (times) trying to crawl out of bed. She needed and voided in toilet each time. -They had added one hour checks to her care plan. *There had been no documentation regarding the following investigation areas: -Interviews conducted with staff members who had been working. -Where the call light had been located. -What level of assistance she required. -If the care plan had been followed. -What the environment looked like upon entering the room. -Who had last worked with her. -If there had been any medication changes. b. Review of resident 41's 12/29/17 fall scene investigation reports revealed: *She was found on the floor at 10:30 a.m. in the resident's room by the bathroom door. -She had been alone and unattended. -Resident stated she was trying to get to the bathroom. -Last time she had been toileted was at 8:30 a.m. --She had been dry but Had a BM right away. -The root cause had been Resident h… | 2020-09-01 |
| 88 | 88 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 657 | D | 0 | 1 | 2S8V11 | **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 care plan reflected physician's orders for one of one sampled resident (40) who used oxygen and a bilevel positive airway pressure ([MEDICAL CONDITION]) device. Findings include: 1. Review of resident 40's medical record revealed: *Her Brief Interview for Mental Status score was fifteen indicating no cognitive impairment. *She had an above the knee amputation of the left leg. *Her [DIAGNOSES REDACTED].>-Type 2 diabetes mellitus. -Sleep apnea. -Heart failure. -Major [MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Gastro-[MEDICAL CONDITION] reflux. -Abnormal posture. -Muscle weakness. *Physician's orders on 4/27/17 for oxygen (02) and [MEDICAL CONDITION]. -Oxygen at 4 liters per minute (lpm) continuous when [MEDICAL CONDITION] not in use. -Oxygen at 10 lpm via [MEDICAL CONDITION] at night and during naps. -[MEDICAL CONDITION] at 16/8 with a backup rate of 12. *Physician's order on 2/2/18 for oxygen. -Oxygen at 2 lpm continuous. -Continue [MEDICAL CONDITION] when sleeping. Observation on 2/27/18 at 3:00 p.m. with resident 40 revealed she had: *Been sitting up in her lift chair taking a nap. *Been wearing oxygen at 2 lpm. *A [MEDICAL CONDITION] machine on her bedside table. Interview on 2/27/18 at 3:00 p.m. with certified nursing assistant (CNA) R regarding resident 40 revealed she used: *Oxygen at 2 lpm during the day. *[MEDICAL CONDITION] at night. Interview on 2/27/18 at 3:15 p.m. with CNA S regarding resident 40 revealed: *She stated I have never seen her wear her [MEDICAL CONDITION] when she takes a nap during the day. *She used oxygen at 2 lpm during the day. Interview and observation on 2/27/18 at 3:30 p.m. with resident 40 revealed: *She had been sitting up in her lift chair and using her oxygen per a nasal cannula. *Oxygen concentrator had been set at 2 lpm. *She stated I only use my oxygen at 2 lpm during the day and 6 … | 2020-09-01 |
| 89 | 89 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 658 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, job description review, and policy review, the provider failed to ensure: *Medications were initialed after being administered by one of one registered nurse (RN) (I) who administered medication to resident 61. *Unlicensed assistive personnel (UAP) (A) had supervision of a registered nurse (RN) to calculate medication doses for two of two sampled residents (14 and 27) who required dosage calculation. *physician's orders [REDACTED]. -One of one sampled resident (10) with a new physician's orders [REDACTED]. -One of one sampled resident (40) who used oxygen and a bilevel positive airway pressure ([MEDICAL CONDITION]) device had been followed. Findings include: 1. Observation on 2/28/18 at 7:50 a.m. of RN I while she prepared medications for resident 61 revealed she signed the resident's medication as having been given as soon as she had finished preparing it. Interview with RN I at that time revealed she had done that because she was only going to administer medication to resident 61. She stated she did not want to have to come back to the medication cart to sign the medication administration record. 2a. Observation and interview on 2/27/18 at 9:00 a.m. of UAP A while she administered medication to resident 27 revealed: *An order on the resident's (MONTH) (YEAR) medication administration record (MAR) stated ranitadine 150 milligrams (mg) (for stomach) in the morning. There ha *There had not been verification on the MAR that had indicated the correct doage was two tablet of ranitadine. *She gave the resident two 75 mg tablets of ranitadine and stated:-She gave two tablets of ranitadine 75 mg to the resident, because there had not been any 150 mg tablets. -There used to be 150 mg tablets. -Now the tablets were 75 mg. -She just knew two 75 mg tablets would equal 150 mg of medication for the resident. -She had not asked a licensed nurse for verification of the correct dose of medication when the table… | 2020-09-01 |
| 90 | 90 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 679 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to provide individualized activities to one of six sampled dependent residents (41). Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had been admitted from the hospital for weakness. *She had been at home prior to that with a care giver. *She had twenty-four falls since her admission on 12/19/17. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. Observation on 2/27/18 at 11:20 a.m. of resident 41 revealed: *She was in her room sitting in her recliner watching the TV. *Her leg was stuck in-between the foot rest of the recliner and the seat. Observation and interview on 2/27/18 at 11:45 a.m. with registered nurse (RN) I regarding resident 41 revealed: *She was lying in her bed. *RN I stated she was told about the resident getting her leg stuck in the recliner. *They were going to remove the recliner from her room due to the incident. *At that time the maintenance director came over to take the recliner out of her room. *RN I stated the resident could not be left alone in her wheelchair without supervision, as she had fallen out of the wheelchair. -She had hit her head as a result of falling out of her wheelchair. Observation on 2/27/18 at 2:10 p.m. of resident 41 revealed she was lying in her bed with no radio or TV on. Observation on 2/27/18 at 4:50 p.m. of resident 41 revealed she was lying in bed with no radio or TV on. She was awake. Observation on 2/27/18 at 6:25 p.m. of resident 41 revealed: *She was lying in bed. *She was attempting to get out of bed. *Both legs were over the scooped mattress. *She was trying to lift her body up. *She was wide awake. *There had been no staff around. Observation on 2/28/18 at 7:29 a.m. of resident 41 revealed she was up in her wheelchair in th… | 2020-09-01 |
| 91 | 91 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 686 | D | 0 | 1 | 2S8V11 | **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 residents (320) who had a diabetic/pressure ulcer received appropriate dietary interventions and services per the physician's orders [REDACTED]. 1. Interview on 2/27/18 at 8:10 a.m. with licensed practical nurse (LPN) C regarding resident 320 revealed: *He: -Had been admitted on [DATE] from an acute care setting. -Was diabetic and had been admitted with two wounds. *She stated He has a black wound to the tip of his right second toe and a small scrape behind his left ankle. -He had a daily dressing change for the wound to his right second toe. -The dressing on his left ankle was changed every three days. *She was unsure how he had gotten the wounds. Observation and interview on 2/27/18 at 8:40 a.m. of resident 320 revealed: *He had: -Been in his room sitting on the edge of the bed. -Been wearing a nasal canula that was hooked up to an oxygen concentrator and running at 2 liters per minutes (LPM). -Gripper socks on his feet. *He stated: -I was in really poor condition when I went to the hospital. -I'm a diabetic and my sugars were very high. -My goal is to go home here really soon. *He had a wound on the tip of his right toe and left ankle. *He stated: -I've been told my toe is a diabetic ulcer. -I fell at the hospital and scraped my left ankle. Observation on 2/27/18 at 12:46 p.m. with LPN C during a dressing change with resident 320 revealed: *She had: -Prepared to change the dressing on his right second toe. -Removed the old dressing and exposed the wound on his toe. *The tip of the resident's toe had been: -Contracted at the first joint, so the tip was in the downward position. -Covered with a brown colored scab. --That scab measured approximately 0.5 centimeters (cm) by 0.5 cm in diameter. *She assessed, cleaned, and applied a new dressing to that wound. *The resident stated: I think it came from a shoe, but I'm not sure. Rev… | 2020-09-01 |
| 92 | 92 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 688 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure a functional restorative therapy program was in place for one of three sampled residents (61) residents who had contractures. Findings include: 1. Observation and interview on 2/27/18 at 8:05 a.m. with resident 61 revealed: *Both hands had observable contractures. -Her left hand side fingers were touching the palms of her hand, and her wrist had contracted toward her forearm. -Her right hand and wrist were slightly less contracted than her left side. *The left arm had been tight against her chest. -A contracture in her left elbow made it impossible for her arm to be straightened. *Her head angled toward the right due to contracture. -She could stretch it toward the left with much effort. *Both legs were unable to lay completely straight due to contracture. *She stated she was unhappy with therapy services. -She would like to walk again but understood she was a long way from that. -She stated her contractures were getting worse. --Her hands, neck, and legs felt tight. --Stretching made it feel better. *She stated she would enjoy more restorative therapy if it were offered. Review of the 3/1/18 physician's orders [REDACTED].>*[DIAGNOSES REDACTED]. *Pain medications included: a [MEDICATION NAME] every seventy-two hours, and as needed [MEDICATION NAME] suppository, [MEDICATION NAME] tablet, and [MEDICATION NAME]-[MEDICATION NAME] tablets. Review of her 2/13/18 care plan revealed: *A focus area of: I am at risk for contractures. *A goal of: I will participate with Restorative Therapy through next review to maintain ROM (range of motion) to UE's (upper extremities), LE's (lower extremities), and neck 2-3x/wk (times per week). 5-10 reps. (repetitions) to prevent further contractures for ADL (activities of daily living) functioning. *Interventions of: Passive ROM to both UE's and LE's 5-10 reps. while in supine or w/c (wheelchair). Passive stretch to neck… | 2020-09-01 |
| 93 | 93 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 689 | G | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to have adequate supervision and interventions in place for one of one sampled resident (41) with multiple falls occurring in the facility and resulting in two major injuries. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had been admitted for weakness from the hospital. *She had been at home prior to that with a care giver. *She had been identified at risk for falls during her admission assessment. *The 12/19/17 fall risk assessment score was twenty-one. -A score of ten or above indicated a risk of falling. -They were to implement the fall prevention protocol and place approaches in the plan of care. --The fall prevention protocol initiated had been: Resident is very confused. She was orientated to call light but does not appear to know how to use this. She will be working with therapy. Will initiate low bed/mat. *She had twenty-four falls since her admission on 12/19/17. -Two of those falls had resulted in major injury, a [MEDICAL CONDITION] on 1/14/18 and a head injury on 2/22/18. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. *She had verbal behaviors that had occurred one-to-three days during the assessment period. *She had not rejected care during the assessment period. *She required assistance of one staff member for the following: -Bed mobility. -Transferring from one location to another. -Locomotion on the unit. -Locomotion off the unit. -Toilet use. -Dressing. -Personal hygiene. *Her [DIAGNOSES REDACTED].>-Cancer. -Hypertension. -Diabetes. -[MEDICAL CONDITION]. *She had a fall prior to admission. *She had one fall with no injury since admission. Review of resident 41's 1/26/18 MDS assessment revealed: *Her BIMS score was zero indicating she had seve… | 2020-09-01 |
| 94 | 94 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 725 | E | 0 | 1 | 2S8V11 | Based on observation, interview, and record review, the provider failed to ensure sufficient nursing staff were available to ensure: *One of three sampled residents (61) received restorative therapy. *One of one sampled resident (41) with multiple falls had been supervised. *Call lights were answered timely to ensure resident needs were met. Findings include: 1. Interview with resident 61 revealed the facility failed to provide her with restorative therapy on a regular basis. Refer to F688, finding 1. 2. Review of resident 41's medical record revealed she had twenty-four falls since her admission on 12/19/17. Refer to F689, finding 1. 3. Resident council meeting on 2/27/18 at 2:25 p.m. with a group of residents and two family members revealed: *They had concerns with the call light wait times. *Staff would come in the room, turn off the call light, and say they would come back later. -They would not always come back. *The wait times got better for a little while but had gotten bad again. Review of the (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) resident council minutes revealed concerns had been brought up about long call light wait times. Refer to F919, finding 3. | 2020-09-01 |
| 95 | 95 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 759 | D | 0 | 1 | 2S8V11 | **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 randomly observed residents' (40 and 56) insulin had been administered according to policy and procedure by one of one licensed practical nurse (LPN) (B). Those observations created a medication error rate of 12.9 %. Findings include: 1. Observation and interview on 2/28/18 from 7:40 a.m. through 7:50 a.m. with LPN B revealed: *During resident 26's [MEDICATION NAME]pen administration she had not held the needle into the resident's skin for more then two seconds after administration and prior to removing it. *During resident 56's administration of the following insulins revealed:-[MEDICATION NAME] 1.8 milligram per 3 ml insulin pen administration. -[MEDICATION NAME] 40 units insulin pen. -[MEDICATION NAME] 7 units insulin pen. She had not held the needles into the resident's skin more than two seconds after administration and prior to removing them. Sherevealed it had been her usual practice to leave the insulin pen in place for only two seconds after injecting the medication. She stated she counted one-thousand-one and one-thousand-two then removed the needle. Interview on 3/1/18 at 8:45 a.m. with the director of nurses revealed: *The above practice by LPN B had been wrong. *Insulin injection pens should have remained inserted in the skin for at least five seconds. Review of the provider's last revised (MONTH) (YEAR) Insulin and Non-Insulin Pen Delivery Systems policy and procedure revealed: *The length of insulin injection times were to have been: -[MEDICATION NAME] 6 seconds. -[MEDICATION NAME] 6 seconds. -[MEDICATION NAME] 6 seconds. *Dose buttons should be pressed down and needle kept under the skin for a full count of seconds to insure the full dose is injected. | 2020-09-01 |
| 96 | 96 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 880 | E | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure: *The Hoyer lift on the 200 hall had cleanable surfaces. *One of one randomly observed resident (10) had clean and unworn hell protector boots. *A bedpan and graduate pitcher in room [ROOM NUMBER] had been stored in a sanitary manner. *A sanitary environment was maintained for: -The storage of resident use equipment in one of one bathroom located on the Transitional Care Unit (TCU). -One of two sampled resident's (320) oxygen tubing when not in use. -The placement of a urinal after it was used for one of one sampled resident (321). -The placement of resident personal care products in two of five randomly observed resident's rooms (110 and 113). -The storage of juice containers in one of one kitchenette on the TCU for one of one juice machine. -The filters in five of five hairdryers located in the main sitting/visiting area on the 300 wing. -One storage room on the 400 wing. Findings include: 1. Observation on 2/27/18 at 11:27 a.m. of the 200 hall Hoyer lift revealed it had a blue fabric and foam covering over the bar where the slings hooked. That covering was opened approximately six inches and had exposed yellow foam poking out. That foam would be uncleanable. 2. Observation on 2/27/28 at 11:35 a.m. of resident 10 revealed she had on heel protector boots. Those boots had Velcro closures. The fabric around the Velcro and on the top and sides of those boots was torn and worn. It was an uncleanable surface. 3. Observation on 3/1/18 at 8:15 a.m. of the bathroom in resident room [ROOM NUMBER] revealed a wash basin and bedpan sitting on the floor directly below the sink. There had been no covering or barriers in place to protect those items from contamination from the floor. 4. Interview on 3/1/18 at 8:45 a.m. with the director of nurses (DON) revealed she agreed: *The padding on the Hoyer lift bar needed replacing and had been an uncleanable surface. *Resident 10's … | 2020-09-01 |
| 97 | 97 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 909 | D | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and manufacturer's manual review, revealed the provider failed to assess the safety for one of one sampled resident's (320) mattress to ensure it was secured to the bed frame and free from unsafe movement. Findings include: 1. Observation and interview on 2/27/18 at 8:57 a.m. with resident 320 revealed: *He had been: -Located in the transitional care unit (TCU). -Sitting on the edge of his bed. *The repositioning bar had been in the down position on the right side of his bed. *The left side of his bed had been placed against the wall. *The bed frame had: -Been exposed underneath of his right leg. -Long metal brackets attached to each end of it. --Those metal brackets were used to secure the mattress in place. *His mattress was not secured in place by those brackets and had shifted sideways on the bed frame. -That movement had created the bed frame to be exposed underneath of his leg by approximately 2 to 3 inches in width. *He confirmed: -He was independent in his room and could transfer himself on and off of the bed. -The mattress had shifted and moved around on the bed frame since he was admitted on [DATE]. *He stated They did offer me another bed, but I refused it as I didn't want to cause any problems. *He denied any injury from the exposed bed frame. Observation on 2/27/18 at 11:50 a.m. of resident 320 revealed: *The resident had just returned from working with therapy and was sitting on the edge of the bed. *The mattress continued to be: -In the same position as observed above. -Not secured in place by the metal brackets. Observation on 2/27/18 at 3:07 p.m. of resident 320 revealed: *He had been lying on his bed resting. *The mattress: -Continued to be not secured in place by the metal brackets. -Had shifted further to the left and moved down towards the foot of the bed. --That movement had exposed a larger portion of the bed frame. *The head of the mattress had moved down to expose approximately 3 inche… | 2020-09-01 |
| 98 | 98 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2018-03-01 | 919 | E | 0 | 1 | 2S8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, manufacturer's review, and policy review, the provider failed to ensure a consistent process was in place for a multi-use call light system to support the resident's needs had been met in a timely and efficient manner. Findings include: 1. Random observations on 2/27/18 from 8:00 a.m. through 9:50 a.m. in the Transitional Care Unit (TCU) revealed: *Most of the residents were out in the dining room eating their breakfast or exercising with the therapists. *The residents observed in the dining room wore a long necklace with a square pendant attached to it. -The center of the pendant contained a rubber type material. *The residents' rooms all had call lights located by their beds and in the bathrooms. *There were no lights above the residents' doors to notify the staff when a resident had turned on their call light. *There was a digital board located at the south end of the hall attached to the wall above the exit door. *The digital board: -Was approximately 20 feet from the dining room area and the nurses' station. -Made a loud beeping noise whenever a resident would push their call light for assistance. -Would only beep once for each call light. -Had large red digital numbers that would run across the board to indicate which resident's room had their call light on. -The room numbers on the board would keep running until staff answered the resident's call light. Interview on 2/27/18 at 8:53 a.m. with resident 320 revealed: *He had been in his room sitting on the bed. *His call light had been clipped to the cord and was hanging against the wall behind the bed's headboard. -That call light was not within his reach. *He had worn a pendant around his neck as observed on the other residents in the dining room. *He stated: -Its what I use for a call light. -I would rather use this than the regular call light. -We can use both, but I prefer to use this one. -I wear it all the time. Interview on 2/27/18 a… | 2020-09-01 |
| 99 | 99 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2019-05-23 | 550 | G | 0 | 1 | LF7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure three of six residents (52, 73, and 125) who required a full body sling with lift transfers were given an option to use a commode or toilet. Findings include: 1. Review of resident 52's medical record revealed:*An admission date of [DATE].*She had a Brief Interview for Mental Status (BIMS) score of two indicating she was severely cognitively impaired.*Her 4/16/19 quarterly Minimum Data Set assessment (MDS) revealed:-She was an extensive assist with a two plus person physical assist for:--Bed mobility.--Transfers.--Dressing.--Toilet use.--Personal hygiene.--Bathing.Interview on 5/21/19 at 8:06 a.m. after resident 52's brief change with certified nurse aides (CNAs) O and P revealed:*She was a Hoyer lift resident.*Residents that are a Hoyer lift and wear a brief are not brought into the bathroom.-It is to hard to get the Hoyer sling off of the resident so they could use the toilet or commode.*They stated residents urinate and have bowel movements (BM) in their brief.-Residents are then changed.*Residents can have a bedpan if they choose.*They are not given the choice to use the toilet.Interview on 5/22/19 at 1:18 p.m. with CNA M concerning resident 52 revealed:*If a resident is a Hoyer lift, their choice is to use a bedpan or urinate or have a BM in their brief.*We check her brief when we lay her down.*She won't use a bedpan.*She uses a Hoyer lift.*We do not toilet her.*I don't know what else we're suppose to do if she will not use a bedpan. She is a Hoyer lift. Interview on 5/22/19 at 1:34 p.m. during resident 52's brief change with CNAs H and N revealed:*They both state they check on her every two hours.*She urinates and has BM's in her brief.*She is a Hoyer lift.*There is no way to toilet her or put her on the commode.-They do not have the correct Hoyer sling to do that. 2. Review of resident 73's 3/29/19 MDS assessment revealed: *She had been admitted on [DATE]… | 2020-09-01 |
| 100 | 100 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2019-05-23 | 656 | E | 0 | 1 | LF7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to develop and revise individual care plans to reflect the needs and desires for eight of nineteen sampled residents (9, 23, 45, 52, 53, 56, 62, and 73). Findings include: 1. Review of resident 56's care plan with a print date of 5/22/19 revealed: *A focus area for a pressure wound. *A new skin area concern on 5/21/19 had not been identified on the current care plan. Refer to F686 finding 4. 2. Review of resident 62's current care plan printed on 5/22/19 revealed: *A focus area for skin breakdown. *The interventions for the above areas had been I am refusing foam boots, staff will continue to offer these. offer pillows to offload heels when in bed. Refer to F686 finding 4. Resident #52 3. Review of resident 52's care plan revealed:*Focus:-I need assistance in:-Dressing. -Grooming. -Bathing.-Date initiated: 10/11/18.*Interventions:-I need extensive assist of one staff with my:-Dressing.-Grooming.-Bathing.-Date initiated:10/11/18. *Her 4/16/19 quarterly minimum data set revealed: -She was an extensive assist with a two plus person physical assist for: --Dressing. --Personal hygiene. --Bathing.*Focus:-Transfers/Bed Mobility/Ambulation.-Date initiated: 10/11/18.*Interventions:-Staff use a sit to stand lift to transfer me.-I need extensive assistance of one staff person with: --Bed Mobility.--Transfers.--Ambulation.-Date initiated: 10/11/18.*Focus: -I am at risk for falls. -Date initiated: 10/11/18.-Revision on 11/6/18. *Interventions: -Do not leave me unattended in my wheelchair in my room, as I may fall out of it. -Date initiated: 1/2/19.Interview on 05/23/19 at 12:30 p.m. with the DON concerning resident 52 revealed she agreed:*She was not to be left alone in a wheelchair in her room.*She was a Hoyer lift.*The careplan needed to be updated to match the Minimum Data Set and her needs.Refer to F550, finding 1 and F684, finding 1. 4. Resident 23 did not have a complete and c… | 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 );