cms_SD: 1580

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

Data source: Big Local News · About: big-local-datasette

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
1580	MENNO-OLIVET CARE CENTER	435113	402 S PINE STREET	MENNO	SD	57045	2017-01-19	514	E	1	0	0GON11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on observation, record review, and interview, the provider failed to ensure the appropriate documentation for: Five of nine sampled residents (1, 2, 3, 4, and 5) who had a history of [REDACTED]. One of one sampled temporary staff nurse (A) for general orientation. Findings include: 1. Review of resident 1's medical record revealed: A 2/25/16 admitted . Diagnoses: [REDACTED]. She sustained a fall with a head injury on 1/7/17. Review of resident 1's 11/9/16 revised care plan revealed she: Had limited mobility of her right hip and knee. Needed one to two staff assistance when using her walker. Required limited to extensive assistance of one staff person with a gait belt to move between surfaces. Had short term memory loss and forgetfulness. Was at high risk for falls related to pain and gait/balance problems. Interview on 1/17/17 at 3:45 p.m. with resident 1 revealed she: Thought her fall was on 1/13/17. Used her walker on her own in her room to walk to and from the bathroom. Did not think she needed anyone to be with her when she walked in her room. Did feel unsteady at times and her legs gave out causing her to lose her balance. Observation on 1/17/17 at 3:50 p.m. on the outside of her room door revealed no documentation of a falling star. 2. Review of resident 2's medical record revealed: A 12/26/16 admitted . Diagnoses: [REDACTED]. She sustained a fall on 1/9/17 with head, neck, and hip injuries. She required an emergency room visit on 1/9/17 for x-rays of her head, neck, and hip. Review of resident 2's 1/10/17 revised care plan revealed she: Required extensive assistance of one staff person to move between surfaces as necessary. Had short term memory loss, loses train of thought, and easily gets distracted. Was at risk for falls related to gait and balance problems, antidepressant use, and history of frequent falls at home. Interview on 1/17/17 at 3:30 p.m. with resident 2 revealed she: Stated she had a bad fall a week or two ago. Had hit her head and left hip. Stated both her head and her left hip still bothered her from the fall. Was taking some pain pills that helped the pain. Stated she had a new left hip, but she was unable to recall when. Felt she could stand up on her own. Felt when she stood up she often felt she was going to fall forward. Had recently fell forward onto her face. Observation on 1/17/17 at 3:35 p.m. on the outside of her room door revealed no documentation of a falling star. 3. Interview on 1/18/17 at 3:55 p.m. with the registered nurse (RN) Minimum Data Set coordinator (MDS) C regarding the above residents revealed she: Stated they should have had a falling star on their room doors to alert the staff of their fall risks. Stated both residents had been identified according to their fall risk assessments as high risk individuals. Usually was the one who put up the falling stars on residents' room doors when they were a fall risk. Stated any resident identified at being as a high fall risk on their care plan should have been identified with a falling star on their room door. 4.Observation on 1/17/17 at 5:32 p.m. outside of resident 3's room revealed there had not been a falling star posted on his door. Review of resident 3's medical record revealed: He had a history of [REDACTED]. The 1/17/17 revised care plan stated he had been a high fall risk related to an unsteady gait, and [MEDICAL CONDITION] episodes. The certified nursing assistant (CNA) pocket care plan had listed him as a fall risk. The 12/29/16 at 8:17 a.m. progress note completed by RN G confirmed resident 3 had been found sitting on the floor in front of his recliner. 5. Observation on 1/18/17 at 10:00 a.m. of resident 4 revealed: Outside of her room was a falling star on the door. She had been asleep in a recliner Broda chair with a padded thigh belt on her upper thighs. The room had a low bed and a mat up against the wall. Review of resident 4's medical record revealed: She had a [DIAGNOSES REDACTED]. The 1/17/17 revised care plan stated she was at a high risk for falls related to Hungtington's disease with chorea movement, use of [MEDICAL CONDITION] medications, and mood disorder. The CNA pocket care plan had not listed her as being a fall risk. 6. Review of resident 5's medical record revealed: He had [DIAGNOSES REDACTED]. The 1/2/17 revised care plan stated he was a high risk for falls related to a history of falls and [MEDICATION NAME] degeneration. The CNA pocket care plan had not listed him as being a fall risk. Observation on 1/17/17 at 5:30 p.m. outside of resident 5's room revealed there had not been a falling star posted on his door. Interview on 1/17/17 at 5:20 p.m. with CNA F revealed: She had been employed at the facility around one year. She knew a falling star on a residents' door indicated they had been at risk for falls. The CNA pocket care plan had not included information on what residents were considered a risk for falls. She had relied on the falling star on the resident's door to inform her who was at risk for falls. Interview on 1/18/17 from 4:25 p.m. through 4:45 p.m. with the interim DON, RN/Minimum Data Set (MDS) coordinator C and the interim administrator regarding the above revealed: Residents who were at risk for falls should have been indicated on the CNA pocket care plan. Residents who were at risk for falls should have had a falling star on their door to alert the staff. Confirmed residents' 3 and 5 had not had a falling star on their doors and should have. Confirmed residents' 4 and 5 had not indicated they were a high fall risk on the CNA pocket care plans and should have. RN/MDS coordinator C was responsible to put the falling star on residents' doors who were at a fall risk. It had been a group effort to update the CNA pocket care plan with residents who were at a fall risk. At a minimum the CNA pocket care plan was updated weekly. They tried to update the CNA pocket care plan after the risk management meetings. CNAs were informed of residents who were at a risk of falls through the falling star on the door and the CNA pocket care plan. There was not a policy for the falling star on residents' doors. There was not a policy for the CNA pocket care plan. 7. Review of licensed practical nurse (LPN) A's employee file revealed: She was a contracted nurse from a contracted/temporary (temp) staffing agency. Her first day of employement had been on 12/28/16. There was a typed note indicating On 12/28/16 LPN A had stopped into the nursing home before her shift that evening. I gave her a tour of the building. The things I showed her were:-The location of the gas turn off valve. -The location of the fire extinguishers, fire pulls, and eyewash stations. -The fire panel and how to operate it. -How to turn the water off. -The supply room with the location of the oxygen. -The automated external defibrillator (AED). -The spill kit. -The suction machine. -The crash cart. -The laundry room. -The clean and dirty utility room. -The location of the material safety data sheets (MSDS) books. -The location of the furnace and hot water heater. -The location of the electrical panel. -The location of the whirlpool and the location of the scale. -The magnets located on the outside of the residents rooms indicting if they are at risk. -The evacuated magnets inside the door. -The note had been signed by the human resource director but not dated or timed when completed. There had been no documentation of general orientation training for a licensed nurse in her employee file. Interview on 1/18/17 at 5:00 p.m. with the interim DON, RN/MDS coordinator C, and the interim administrator regarding LPN A's general orientation for a licensed nurse revealed: LPN A's first day of work was 12/28/16. LPN A had been employed with a contracted staffing agency. The human resource director had gone through papers with LPN [NAME] RN/MDS coordinator C had trained LPN A the night of 12/28/16. LPN A had needed very little training on the electronic medical record (EMR) and point click care (PCC). RN/MDS coordinator C had gone over PCC with LPN A but had not documented that. LPN A had been shown the risk management portion of the EMR that included incident reports and fall reports. There had not been a general orientation for licensed nurse document completed for LPN [NAME] They had not documented any general orientation training for LPN [NAME] There was not a general orientation policy for licensed nurses from temporary staffing agencies. Review of the contract between the facility and the contracting temporary staffing agency signed by the interim administrator on 9/6/16 revealed: Client Facility Responsibilities: -D. Client Facility agrees that a proper orientation will be conducted to ensure a safe working environment.	2020-01-01