cms_SD
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4411 | 4411 | CENTERVILLE CARE AND REHAB CENTER | 435088 | 500 VERMILLION ST | CENTERVILLE | SD | 57014 | 2012-07-25 | 221 | D | 0 | 1 | 00I811 | **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 (6) with a physical restraint had ongoing assessment, documentation, and care planning for continued use. Findings include: 1. Observation on 7/24/12 at 3:45 p.m. revealed resident 6 had been sitting in her wheel chair with a seat belt around her middle section. Review of resident 6's complete medical record revealed: *An admission date of [DATE]. *A [DIAGNOSES REDACTED]. *Minimum Data Set ((MDS) dated [DATE] noted trunk restraint was used less than daily. *MDS dated [DATE] noted trunk restraint was used daily. *Care assessment area for Physical restraints dated 11/17/11 revealed: -Trunk restraint was used in chair or out of bed. -Resident has a history of [MEDICAL CONDITION] with involuntary movments. Has trunk restraint to keep torso (upper part of human body, not involving head and arms) from falling forward. -Physical therapy has been helpful in evaluation and making recommendations for appropriate equipment to meet her needs safely. Resident is unable to remove seat belt due to her contractures to hands bilat (bilaterally). -Seat belt will be comfortable and minimize anxiety. *Physician's order dated 5/23/12 revealed no order for a restraint. *Care plan dated 5/8/12 revealed no information for use of a restraint. Interview on 7/24/12 at 4:15 p.m. with the director of nursing (DON) revealed: *Resident 6: -Had been admitted on [DATE] with a seat belt restraint. -Was unable to physically remove the seat belt restraint. *The restraint was not on the care plan. *There was no physician's order for restraint usage. *She had not done a restraint assessment for the resident. *Staff had not been monitoring seat belt usage for the resident. Observation and interview on 7/24/12 at 4:25 p.m. with resident 6 revealed she was unable to remove the seat belt. Interview on 7/25/12 at 7:40 a.m. with the DON revealed she: *Had not con… | 2015-09-01 |
| 4412 | 4412 | CENTERVILLE CARE AND REHAB CENTER | 435088 | 500 VERMILLION ST | CENTERVILLE | SD | 57014 | 2012-07-25 | 279 | E | 0 | 1 | 00I811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the provider failed to identify and plan for resident's conditions and services needed on the care plan for three of seven sampled residents (2, 6, and 7). Findings include: 1. Review of resident 7's revised care plan dated 6/19/12 did not reveal an integrated care plan between hospice and the provider. Review of resident 7's medical record revealed: *He had started on hospice on 6/1/12. *His 6/7/12 significant change Minimum Data Set (MDS) assessment had been completed due to his status change to hospice. Interview with the director of nursing (DON) at 10:30 a.m. on 7/25/12 revealed she confirmed resident 7's care plan did not include any identified hospice services and no directions for when hospice was to be notified or involved with his care. Interview with the social services designee (SSD) at 10:45 a.m. on 7/25/12 revealed: *She had never done a care plan that involved hospice services since she had started as SSD in April 2012. *The provider had not had a hospice resident for a long time. *She had just received the integrated care plan check list and had planned to work on it with the social services consultant on 7/27/12. *She confirmed there was no identification on the care plan that resident 7 was on hospice, what his needs were, and what the plan was for hospice's involvement. Review of the undated Integrated Hospice Care Plan Checklist the SSD had just received revealed: *1. On day of admit to hospice (or within 48 hours), the hospice admitting nurse will consult with MDS nurse so that a care plan can be jointly developed. Items to be addressed must include: -Reason for hospice involvement (diagnosis). -Planned visits-by whom and how often. -Medication and equipment needs and who will provide. -When hospice should be called, who to call and phone number. -Comfort interventions, medications and non-pharmological.-Spiritual needs/psycho-social needs. -Environmental issues (room ad… | 2015-09-01 |
| 4413 | 4413 | CENTERVILLE CARE AND REHAB CENTER | 435088 | 500 VERMILLION ST | CENTERVILLE | SD | 57014 | 2012-07-25 | 281 | E | 0 | 1 | 00I811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to: *Document the results of as needed (PRN) medications for two of eight sampled residents (4 and 8). *Follow the discontinuation of medication order policy for one of seven sampled residents (5). Findings include: 1. Review of resident 4's medication (med) notes for June and July 2012 revealed: *an order for [REDACTED]. *In June there was no follow-up documentation twenty-five times. *In July there was no follow-up documentation thirty-two. *an order for [REDACTED]. *In June there was no follow-up documentation six times after the medication had been administered. *In July there was no follow-up documentation three times after the medication had been administered. 2. Review of resident 8's closed medical record revealed: *An admission date of [DATE]. *She had left the faciity on [DATE] against medical advice. *physician's orders [REDACTED].>-[MEDICATION NAME] 1 mg orally twice daily PRN, there was no follow-up documentation thirteen times. -[MEDICATION NAME] 220 mg two tablets orally twice daily for pain PRN, there was no follow-up documentation seven times. -[MEDICATION NAME] 5/500 mg one tablet orally every four to six hours PRN, there was no follow-up documentation twenty-one times. -[MEDICATION NAME] DM one tablet orally twice daily for cough PRN, there was no follow-up documentation five times. 3. Interview on 7/24/12 at 4:30 p.m. with the director of nursing (DON) regarding findings 1 and 2 confirmed she would expect staff to have documented on the results of any PRN medication administered to the residents. Review of the provider's October 2009 procedure for Administration of Medication revealed there should have been documentation of results such as pain relief, etc (and so on) on the back of the medication administration sheet or on the interdisciplinary progress notes. 4. Review of resident 5's Medication Administration Record [REDACTED] *A pattern of crossi… | 2015-09-01 |
| 4414 | 4414 | CENTERVILLE CARE AND REHAB CENTER | 435088 | 500 VERMILLION ST | CENTERVILLE | SD | 57014 | 2012-07-25 | 514 | D | 0 | 1 | 00I811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to keep an accurate record on bowel elimination for one of seven sampled residents (2). Findings include: 1. Review of resident 2's medical record revealed she: *Had [DIAGNOSES REDACTED]. *Needed extensive assistance with activities of daily living and hygiene. *Needed cueing to go to the bathroom. *Was on [MEDICATION NAME] 100 milligrams two tablets orally every morning, and [MEDICATION NAME] one tablet every evening for constipation. Review of resident 2's care plan dated 7/3/12 revealed the only plan and approaches for self care deficits related to her dementia were scheduled toileting upon rising, before and after meals and activities, bedtime, and as needed. Review of resident 2's bowel movement (BM) record from 1/1/12 through 7/23/12 indicated the resident had gone from three days up to fourteen days without a BM. Interview on 7/24/12 at 3:15 p.m. with the director of nursing revealed: *Resident 2 was out with her husband most of the day. *The husband would take her out after lunch and would return to eat supper with her. Then would sometimes take her out again after supper, and return her to the facility in the evening. *She had felt there was no way to keep track of the resident's BMs. *She agreed the care plan should have reflected the resident would leave with her husband much of the day. *She agreed there should have been some follow-up after three days without a BM. *There was no policy for BM elimination, but if a resident had not had a BM for three days there would have been some intervention done. | 2015-09-01 |
| 3715 | 3715 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 164 | D | 0 | 1 | 00LU11 | Preceptor: Based on observation, interview, and policy review, the provider failed to ensure privacy and confidentiality of resident information was maintained: *From possible tampering and theft for resident records left at one of five exits (employee entrance). *For the resident identification list for one of one posted 2012 survey results. Findings include: 1. Observation on 3/26/13 at 3:20 p.m. in the employee entrance foyer area next to the door revealed: *Two interdepartmental manilla folders in an open, clear, plastic holder affixed to the wall labeled PL (Prairie Lake) Hospital and Sanford Clinic. *One interdepartmental manilla folder in an open, clear, plastic holder affixed to the wall labeled Brown Clinic and Other Misc. (Miscellaneous) Clinics. *One visitor and one employee entered through that entrance door. *One employee exited through that entrance door. Interview on 3/27/13 at 9:38 p.m. with the director of nursing (DON) in her office revealed: *The above noted holders were used for residents' information exchange with the hospital and local clinics. *The holders had been there since January 2011 when she had started working as DON at the facility. *Visitors seldom used the employee entrance. Interview on 3/27/13 at 11:22 a.m. with the interim administrator in the employee entrance foyer area revealed: *The resident information placed in the holders was not in a good location. *That system of resident information exchange needed to be changed to a more secure and confidential method. 2. Observation on 3/26/13 at 7:50 a.m. of the 1/05/12 survey results posted next to the director of nursing's office revealed: *The resident identifier list had the following CONFIDENTIAL - DO NOT POST. *The employee identifier list had the following CONFIDENTIAL - DO NOT POST. Interview on 3/26/13 at 2:00 p.m. with the interim administrator revealed those identifier lists were confidential. They should not have been in the posted survey results. Review of the provider's Notice of Privacy Practices policy dated Januar… | 2016-09-01 |
| 3716 | 3716 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 166 | C | 0 | 1 | 00LU11 | Preceptor: Based on record review of resident council minutes, interview, and policy review, the provider failed to have a system in place that addressed grievances brought up in the resident council meetings. Findings include: 1. Interview on 3/26/13 at 9:30 a.m. with seven resident council members revealed: *Individual issues brought up outside of council meetings were addressed and brought back to the specific resident. *Group concerns discussed in council meetings were not followed-up on at the next months council meeting. *They had brought up dietary concerns on 3/25/13 at the resident council meeting and had been instructed to complete a grievance form. Review of the resident council minutes for the past six months revealed: *There were fifteen to twenty-two residents who had attended resident council meetings. *On 12/18/12 one concern had been noted about residents who wanted to pick out their own clothes. *On 1/22/13 no concerns or follow-up for the above mentioned concern had been noted. *On 3/25/13 no concerns or follow-up on the dietary concern had been noted. *The minutes form stated If only one resident has the concern do not list it below, instead, write it as a referral to the appropriate department. Review of the undated policy Guidelines for Resident Council revealed the provider was required to listen to recommendations or concerns made by the residents. The provider should have communicated any decisions about those recommendations or concerns back to the resident council. Interview on 3/26/13 at 10:20 a.m. with the ombudsman revealed she had attended the resident council meetings at the facility for the last six months. She stated the 3/25/13 meeting was the first time she had heard the residents make so many complaints about the dietary service. Interview on 3/27/13 at 8:15 a.m. with the activity coordinator revealed: *If a single resident stated a concern during the resident council meeting that concern was not documented on the resident council meeting form, according to the directions on t… | 2016-09-01 |
| 3717 | 3717 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 281 | D | 0 | 1 | 00LU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to follow physician's orders for a laboratory test for 1 of 11 (5) sampled residents. Findings include: 1. Review of resident 5's March 2013 physician's order sheet titled All Active Orders for March 2013 revealed: *Diet order - Con CHO (Consistent Carbohydrate). -Special instructions: Heart Healthy - 2000 ADA (Diabetic diet for 2000 calories). -Order was dated 12/6/12. *Hgb (hemoglobin) A1C (laboratory blood glucose test for diabetes) in 2 months. -Order was dated 11/6/12. Review of resident 5's laboratory blood tests completed from 11/1/12 through 3/25/13 revealed the following Hgb A1C test: *Hgb A1C had been tested on [DATE]. -Resident was in the hospital at that time, and the test had been done there. -Test results were 7.4% (percent). Reference range used was 4.3 - 6.4%. -The test identified the amount of control for blood glucose. *No other tests for the Hgb A1C test were found. Interview on 3/26/13 at 2:30 p.m. and on 3/27/13 at 9:30 a.m. with the director of nursing services revealed: *There had not been a Hgb A1C test done in two months following the 11/6/12 physician's order for resident 5. *She was aware they had not completed that test. *The consultant pharmacist had mentioned it to them in February 2013. *She had put it on the calendar for the clinic to complete on their 2/28/13 laboratoy test date. *They were not aware the test had not been completed until 3/20/13 when the consultant pharmacist had told them it still had not been completed. *They had it on the calendar for the clinic to complete that test on 3/28/13 | 2016-09-01 |
| 3718 | 3718 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 325 | D | 0 | 1 | 00LU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the provider failed to assess and monitor nutritional parameters for one of five (5) sampled residents with weight concerns. Findings include: 1. Review of resident 5's medical record revealed he: *Had been admitted on [DATE] following a hospital stay for a [MEDICATION NAME] accident ([MEDICAL CONDITION]) *Had been admitted for rehabilitation with plans to be discharged . *Had [DIAGNOSES REDACTED]. *Was given 30 units of insulin every day at 5:00 p.m. for his diabetes. *Had a sliding scale for insulin with blood glucose checks taken four times a day: before meals and at HS (hour of sleep). *Had a diet order dated 12/6/12 for a consistent carbohydrate (Con CHO) with special instructions to include a Heart Healthy, 2000 (calorie) ADA (American Diabetes Association) diet. *Had an A1c Hemoglobin blood test result of 7.4% (percent) on 11/01/12. Normal range was 4.3 - 6.4% *Had a physician's laboratory order dated 12/13/12 for an A1c test to be completed in two months. *Had another medication started on 2/19/13 for constipation. Review of resident 5's weight record revealed: *11/11/12 was 267 pounds (lb). *11/14/12: 257 lb. *11/25/12: 250 lb. *12/02/12: 245 lb. *12/11/12: 246 lb *Twenty-one lb weight loss at one month (11/11/12 - 12/11/12) = 8% loss of body weight. *12/23/12: 243 lb. *12/30/12: 240 lb. *01/06/13: 237 lb. *01/13/13: 236 lb. *01/27/13: 231 lb. *02/03/13: 228 lb. *02/04/13: 233 lb. *02/12/13: 226 lb *Forty-one lb weight loss at three months (11/11/12 - 2/12/13) = 15% loss of body weight. *02/25/13: 220 lb. *02/26/13: 227 lb. *03/03/13: 218 lb. *03/17/13: 215 lb. *03/24/13: 214 lb. *Fifty-three lb weight loss (11/11/12 - 3/24/13) = 19.7% loss of body weight. Interview on 3/26/13 at 3:00 p.m. and on 3/27/13 at 8:15 a.m. with the provider's registered dietitian (RD) regarding resident 5's diet order, weight, meal intakes, and an HS snack revealed: *She had educated him and encouraged hi… | 2016-09-01 |
| 3719 | 3719 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 363 | D | 0 | 1 | 00LU11 | Based on record review, observation, and interview, the provider failed to coordinate diet extension menus with the regular menus listed on the Week At A Glance Menu sheet for all residents on oral diets. Findings include: 1. Comparison review of the preplanned Week One Diet Extension menus with the Week-At-A-Glance menus dated March 24 through 30, 2013 revealed they did not match. Review of the preplanned regular menu on both the Week-At-A-Glance and the Week One Diet Extension for the Monday evening meal revealed: *Week-At-A-Glance regular diet menu: -Swedish meatballs. -Swedish mushroom sauce. -Mashed potatoes. -Callifornia vegetables. -Diced pears *Alternate regular diet menu choice: -Italian seasoned fish fillet. -Squash. -Green beans. *Dinner roll and diced pears. *Week One Diet Extension regular diet menu: -Winter squash soup and crackers, -Philly beef sandwich, -Steak fries (6) and ketchup. -Whole strawberries and whip topping. *Alternate regular diet menu choice: -Crispy fish sandwich. -Tomato slice. -Bean medley. -Ice cream cup. *Week One Diet Extension Consistent Carbohydrate (Con CHO) diet menu for diabetics: -No soup and crackers) -Philly Steak sandwich. -Steak fries (3 instead of 6) and no ketchup. -Strawberries with whip topping. *Alternate Con CHO menu choice for diabetics: -Same as the alternate regular diet menu of fish sandwich, tomato slice, and bean medley. -Fruit cocktail instead of ice cream cup. Observation on 3/25/13 at 5:00 p.m. of the food prepared for the Monday evening meal revealed it matched only the Week-At-A-Glance preplanned menu. There was no Philly steak sandwich, steak fries, winter squash soup as preplanned on the regular and Con CHO diet for diabetics. Only the following food items were prepared: *Regular diet menu: -Swedish meatballs. -Swedish mushroom sauce. -Mashed potatoes. -Callifornia vegetables. *Alternate regular diet menu choice: -Italian seasoned fish fillet. -Squash. -Green beans. -Dinner roll -Diced pears. Comparison review of the Tuesday noon meal on the Week-At… | 2016-09-01 |
| 3720 | 3720 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 367 | D | 0 | 1 | 00LU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preceptor: Based on observation, interview, record review, and guidelines review, the provider failed to ensure therapeutic diets prescribed by the physician were served as ordered for two of five sampled residents (5 and 8). Findings include: 1. Record review on 3/26/13 at 11:30 a.m. of resident 8's medical record revealed: *A physician's orders [REDACTED]. *A protein bar to be given at [MEDICAL TREATMENT], one bar three times per week. Review of the registered dietitian's (RD) diet orders sheet updated on 3/26/13 revealed resident 8's diet was for a Renal, 1800 kcal (kilocalorie) ADA. Observation on 3/26/13 at 12:40 p.m. in the main dining room of resident 8 revealed: *He consumed 100% (percent) of four ounces of Nepro supplement and two ounces of water. *He consumed 100% of polish sausage with creamy mustard sauce, 25% of country potatoes, and 100% of lemon cake. *He chose his meal via a selective menu sheet with the items circled on the sheet. Record on 3/27/13 of resident 8's meal and snack intake record from 2/01/13 to 3/26/13 revealed: *He ate 100% of forty-four of fifty-six documented meals and snacks. *He ate 50% of one of fifty-six documented meals and snacks. *He ate 25% of one of fifty-six documented meals and snacks. *He ate none to very little of twelve of fifty-six documented meals and snacks. Interview on 3/26/13 at 6:00 p.m. with resident 8 in his room revealed: *He did not want to come out for the evening meal. *He had requested a room tray with meatballs and mushroom gravy and bread pudding. *He liked to choose what he ate, and he liked certain foods. Review of the provider's undated Renal Diet for menu planning sheets revealed the renal diet was 50-60 grams per day of protein, 1,000- 3000 milligrams per day of sodium, 2,000-3,000 milligrams per day of potassium, and 1,000 milligrams per day of phosphorus. Review of the provider's Summer 2012 Nutritional Information resource for the diet manual and current menu cycle reveal… | 2016-09-01 |
| 3721 | 3721 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 441 | E | 0 | 1 | 00LU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preceptor: Based on observation, interview, policy review, and record review, the provider failed to ensure appropriate sanitary practices for: *The cleaning and disinfecting of the bath chair between residents' use in one of one whirlpool room (Long hall). *Multiple use resident items (razors, nail clippers, combs, hair pick, and hair brushes) in two of two whirlpool rooms (Long hall and Short hall). *Proper handwashing technique for one of one sampled resident's 1 dressing change. Findings include: 1. Observation on 3/26/13 at 8:15 a.m. in the whirlpool room on Long hall with CNA A revealed: *The Penner bath chair, arms, and strap were sprayed with undiluted Penner Classic Whirlpool Disinfectant Cleaner. *The foot pedals and the base of the bath chair were not sprayed with the disinfectant. *The bath chair, arms, and strap were wiped with a dry, white towel. *Visible gray hair was on the hair pick and the hair brush. *One of the razors was opened and multiple, short, gray hairs were present. Interview at the above time with CNA A revealed: *The bath chair was used for weighing residents throughout the day. *The bath chair was submersed in the whirlpool tub for disinfecting at the end of each day shift. *Two nail clippers, multiple combs, one hair pick, one hair brush, and the two Philips Norelco razor heads were cleaned with 70% (percent) [MEDICATION NAME] alcohol preparation pads after each use. *Visible gray hair was on the hair pick and the hair brush. *One of the razors was opened and multiple, short, gray hairs were present. Interview on 3/27/13 at 8:30 a.m. in the whirlpool room on Long hall with RN B revealed: *The bath chair should have been properly cleaned and disinfected after each resident use. *Resident items including combs, hair picks, hair brushes, razors, and nail clippers should have been cleaned after each use. *The toothbrush was used to clean out the inside of the razors. Observation on 3/27/13 at 8:30 a.m. in the Short… | 2016-09-01 |
| 3722 | 3722 | GOLDEN LIVINGCENTER - WATERTOWN | 435068 | 415 FOURTH AVE NE | WATERTOWN | SD | 57201 | 2013-03-27 | 468 | B | 0 | 1 | 00LU11 | Based on observation, interview, and testing the provider failed to have firmly secured handrails in the west and southeast hallways. Findings include: 1. Observation, interview and testing on 3/27/13 at 7:50 a.m. with the maintenance supervisor in the west and southeast hallways revealed: *The west hallway handrail by the central nurses station was not firmly secured. The end of that handrail moved an inch or more away from the wall when any weight was applied to it during testing at that time. *The handrails in the southwest hallway between resident rooms 24 and 30 were not firmly secured to the wall and moved when tested . *The maintenance supervisor agreed the handrails in the above noted locations were not firmly attached to the walls as required. *The maintenance supervisor had been having problems keeping the handrails firmly attached ever since they were installed. | 2016-09-01 |
| 1319 | 1319 | SANFORD CARE CENTER VERMILLION | 43A098 | 125 S WALKER STREET | VERMILLION | SD | 57069 | 2017-05-04 | 280 | D | 0 | 1 | 04AV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to appropriately update and revise the care plan for one of thirteen sampled residents (3). Findings include: 1. Observation on 5/2/17 at 9:17 a.m. of resident 3's abdomen revealed she had a percutaneous endoscopic gastrostomy (PEG) tube. Review of resident 3's entire medical record revealed: *She was admitted on [DATE]. *She had [DIAGNOSES REDACTED]. *On 4/5/17 she had a percutaneous endoscopic gastrostomy (PEG) tube inserted for tube feedings. *On 4/6/17 she had tube feedings started. *On 4/14/17 she had been placed on the medication [MEDICATION NAME] for anxiety or sleep. *On 4/27/17 her code status had been changed from full code to do not resuscitate (DNR). Review of resident 3's 1/24/17 revised care plan revealed: *Her code status had been listed as full code. *No mention of the current PEG feeding tube. *No mention of the use of the [MEDICAL CONDITION] medication. Interview on 5/3/17 at 10:40 a.m. with the Minimum Data Set coordinator revealed: *The care plan for resident 3 had not been updated to reflect her current status. *It was her responsibility to update the care plans. Interview on 5/4/17 at 8:00 a.m. with the director of nursing revealed she would have expected the care plan to have been accurate and updated to reflect the resident's current care needs. Review of the provider's policy revised 1/10/17 Resident Assessment and Interdisciplinary Care Planning Process revealed: Assessing and determining the interdisciplinary care for each resident will be timely, complete, and communicated to all persons involved in the care of that resident. | 2020-09-01 |
| 3672 | 3672 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 176 | E | 0 | 1 | 05H511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure residents who were self-administering medications had physician's orders to allow the self-administration, had assessments completed indicating it was a safe practice, and had care planned the self-administration of the medication for four of nine sampled residents (3, 5, 6, and 8). Findings include: 1. Review of the 2012-2013 resident bedside medication education sheet revealed: *Resident 5 kept the following medications at the bedside: -[MEDICATION NAME] gel to be used as needed (PRN). -Tucks extra strength PRN. -Artifical tears PRN (kept in the medication cart per resident's request). -[MEDICATION NAME] PRN. *There was documentation for the monitoring of the medication dated from November 2012 to February 2013. *The quarterly assessment completed at the top of the resident's bedside medication education record had not been dated or signed by the nurse who had completed the assessment. Interview on 2/13/13 at 10:45 a.m. with nurse A confirmed the quarterly assessment had not been dated or signed by the person completing the assessment. The assessment was completed each time a new record was placed in the resident's medical record and had been initiated which was every six months. She was not aware a self-administration assessment needed to be completed each quarter. Review of resident 5's care plan revealed no documentation regarding self-administration of medications. Interview on 2/13/13 at 11:00 a.m. with nurse B revealed: *Resident 5 liked to sleep late in the morning. *The night-shift nurse left resident 5's before breakfast medications on her bedside table for her to take when she had awakened. *The night-shift nurse set the medications up sometime between 5:00 a.m. and 6:30 a.m. and left them in resident 5's room. Review of the January 2013 medication record revealed resident 5 was to receive the following medications before breakfast: *[MEDICATION NAME] 40 milligram… | 2016-10-01 |
| 3673 | 3673 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 280 | E | 0 | 1 | 05H511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure residents' care plans for six of nine sampled residents (2, 3, 5, 6, 7, and 8) were developed, reviewed, and revised for appropriate problems, goals, and approaches. Findings include: 1. Observation and interview on 2/13/13 at 8:15 a.m. with registered nurse (RN) A during resident 7's 8:00 a.m. scheduled tube feeding revealed: *The placement of resident 7's feeding tube was verified as being at 3. *RN A did not check for placement of the feeding tube by introducing water and listening for a bubbling or gushing sound. *RN A did not check for residual stomach contents. *RN A stated she had been told resident 7's type of tube did not have to be checked for placement, and the physician did not want residuals checked. Review of resident 7's medical record revealed: *He had a percutaneous endoscopic gastrostomy (PEG) tube (feeding tube) placed on 11/15/12. *There was a 12/21/12 hospital discharge summary with discharge instructions for resident 7 to have [MEDICATION NAME] 1.2 calories per milliliter (ml), 280 ml every four hours followed by 150 ml of water. *There were no other instructions related to placement checks for his PEG tube. *A 1/24/13 physician's re-certification order indicated the above findings. Continued interview and record review on 2/14/13 at 8:00 a.m. with RN A revealed she had further documentation that had been at the nurses station in regards to resident 7's PEG tube. The instructions were handwritten and noted by RN A on 12/21/13. Those instructions included to check the placement of the PEG tube - #3 are on the tube. RN A stated that #3 was what had been marked on the tube when he had been admitted . She stated the tube had never moved and had always stayed on #3. Review of resident 7's updated 1/8/13 care plan revealed no intervention in regards to checking for placement of the PEG tube or gastric content. Review of the provide… | 2016-10-01 |
| 3674 | 3674 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 281 | E | 0 | 1 | 05H511 | **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 (7) with a feeding tube had physician's orders [REDACTED]. *Two of sixteen residents' (7 and 11) medications had been administered correctly. *One of nine sampled resident's (2) had physician's orders [REDACTED]. Findings include: 1. Observation and interview on 2/13/13 at 8:15 a.m. with registered nurse (RN) A during resident 7's 8:00 a.m. scheduled tube feeding revealed: *The placement of the feeding tube was verified as being at 3. *RN A did not check for placement of the feeding tube by introducing water or air and listening for a bubbling or gushing sound. *RN A did not check for residual stomach contents. *RN A stated she had been told the resident's type of tube did not have to be checked for placement, and the physician had not wanted residuals checked. Review of resident 7's medical record revealed: *He had a percutaneous endoscopic gastrostomy (PEG) tube (feeding tube) placed on 11/15/12. *There was a 12/21/12 hospital discharge summary with discharge instructions for the resident to have [MEDICATION NAME] 1.2 calories per milliliter (ml), 280 ml every four hours followed by 150 ml of water. *There were no other instructions related to placement checks for his PEG tube. *A 1/24/13 physician's re-certification order indicated the above findings. Continued interview and record review on 2/14/13 at 8:00 a.m. with RN A revealed she had further documentation that had been at the nurses station in regards to resident 7's PEG tube. The instructions were handwritten and noted by RN A on 12/21/13. Those instructions included to check the placement of the PEG tube - #3 are on the tube. RN A stated that #3 was what had been marked on the tube when he had been admitted . She stated the tube had never moved and had always stayed on #3. Interview on 2/14/13 at 8:30 a.m. with the director of nursing (DON) and RN B regardin… | 2016-10-01 |
| 3675 | 3675 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 323 | D | 0 | 1 | 05H511 | Based on observation and interview, the provider failed to ensure cleaning chemicals were inaccessible to the residents in toilet rooms and the B wing shower and tub room. Findings include: 1. Random observations from 2/12/13 at 9:45 a.m. to 2/13/13 at 5:00 p.m. revealed a quaterany cleaning chemical was stored in multiple residents' toilet rooms and in the B wing shower and tub room in a manner that allowed resident access. Interview on 2/13/13 at 3:00 p.m. with nurse A revealed she thought the chemicals could be stored in the residents' toilet rooms on a shelf if it was out of reach of the residents. She confirmed the chemical stored in some of the residents' toilet rooms would be resident accessible.The chemical stored on the shelving in the shower/tub room was accessible to residents. | 2016-10-01 |
| 3676 | 3676 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 356 | C | 0 | 1 | 05H511 | Based on observation and interview, the provider failed to ensure nurse staffing hours had been posted for residents and visitors. Findings include: 1. Observation from 2/12/13 through 2/14/13 revealed no information had been posted regarding the nurse staffing schedule. Interview on 2/14/13 at 10:00 a.m. with registered nurse A revealed: *The nurse staffing list was kept in the nurses charting area. *The list was not posted for residents and visitors. Interview on 2/14/13 at 11:30 a.m. with the director of nurses revealed: *The nurse staffing hours had been posted previously. *She was not aware the nurse staffing hours were not currently being posted. *She was aware they were required to be posted. | 2016-10-01 |
| 3677 | 3677 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 371 | E | 0 | 1 | 05H511 | Preceptor: Based on observation and interview, the provider failed to maintain sanitary conditions in the dietary department. Findings include: 1. Observations from 2/12/12 through 2/13/13 revealed the wire shelving for clean equipment, dishes, and food in the kitchen, dishwasher area, and one of one walk-in cooler had the following: *Wire shelving for the clean items from the dishwasher had the plastic coating missing revealing bare metal on three of three shelves making it an uncleanable surface (photos 1 and 2). *Wire shelving for the clean items in the kitchen preparation area had the plastic coating missing on the edge revealing bare metal on two of two shelves making it an uncleanable surface (photo 3). *The wall behind the sink in the dishwasher room was in disrepair, revealing exposed bare fiber board making it an uncleanable surface (photo 4). *Wire shelving in the walk-in refrigerator had the plastic coating missing revealing bare metal and rust on two of four shelves making it an uncleanable surface (photo 5). Interview on 2/13/13 at 11:15 a.m. with the certified dietary manager revealed: *She agreed the shelving and wall were not cleanable surfaces. *The provider did not have policies to reflect cleanable surfaces in the kitchen. | 2016-10-01 |
| 3678 | 3678 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 431 | F | 0 | 1 | 05H511 | Preceptor: Based on observation, interview, testing, and policy review, the provider failed to: *Maintain a separately locked permanently affixed compartment for all of the schedule II narcotics (pain medication) in one of one medication cart. *Ensure one of one medication cart remained secured. *Accurately reconcile and account for all controlled medications for destruction. *Ensure medications had not been left unattended with a resident during a tube feeding. Findings include: 1. Observation on 2/12/13 at 2:55 p.m. of the medication cart revealed the following schedule II narcotics had not been secured in the top drawer of the medication cart: *Oxycodone 5 milligram (mg) tablets, 10 tablets. *OxyContin 20 mg tablets, 19 tablets. *Those medications had not been in a separately locked compartment. Interview on 2/14/13 at 10:30 a.m. with the director of nursing (DON) confirmed her expectation would have been for all schedule II narcotics to have been appropriately locked up. 2. Observation on 2/12/13 from 4:50 p.m. to 5:30 p.m. of registered nurse (RN) C revealed: *The medication cart had not been locked while RN C had passed medications in residents' rooms. -Several staff and residents had walked by the unlocked medication cart in the hallway. -The RN's back had been turned away from the medication cart while she passed medications in residents' rooms. *The medication cart had not been locked while RN C passed medications in the dining room. - The RN's back had been turned away from the medication cart numerous times. -Several staff and residents had walked by the unlocked medication cart in the dining room. Review of the provider's administration of medication policy dated 6/01/02 revealed the medication cart should have never been left opened and unattended. Surveyor Observation and and cart freely opened by surveyor on 2/12/13 from 4:50 p.m. through 5:30 p.m. of the security of the medications in that medication cart revealed: *It had been parked in the north end of the dining room. *RN C had been using the c… | 2016-10-01 |
| 3679 | 3679 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 441 | E | 0 | 1 | 05H511 | Preceptor: A. Based on observation, interview, and policy review, the provider failed to ensure a sanitary environment to prevent cross-contamination for: *Three of three observations of resident's 4 and 7 blood sugar testing. *One of one resident's (7) dressing change. Findings include: 1. Observation on 2/12/13 at 12:00 noon of registered nurse (RN) C providing care to resident 4 revealed she: *Had brought a shared diabetic supply tub containing clean supplies into the resident's room. *Had washed her hands for five seconds before donning gloves. *Had checked the resident's blood sugar with the glucometer (blood sugar monitor). *Used her soiled gloved hand to turn on the water at the bathroom sink. -Those same gloves had been used to check the resident's blood sugar. *Placed the uncleaned glucometer back into the tub of clean supplies potentially contaminating the clean diabetic supply tub. Interview on 2/14/13 at 10:00 a.m. with the director of nursing agreed that her expectation would have been: *The glucometer should have been cleaned after each use. *The uncleaned glucometer should not have been placed back into clean supplies. *Appropriate handwashing of twenty-five to thirty seconds should have occurred between glove changes. *Supplies should not have been cross-contaminated while providing resident care. 2. Observation on 2/13/13 from 8:05 a.m. through 8:30 a.m. revealed RN B while providing a dressing change and tube feeding for resident 7 included: *She entered the resident's room with a tray that contained medications, dressing change supplies, and a new tube feeding syringe. *She washed her hands, put gloves on and then checked the resident 's blood sugar. *She removed her gloves and without washing her hands left the room to retrieve the resident's sliding scale insulin order. *She returned to the room, washed her hands, put on gloves, removed those gloves, and then left the room again to retrieve an insulin syringe. *She returned to the room, washed her hands, and put on gloves. *She gave the resid… | 2016-10-01 |
| 3680 | 3680 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 514 | E | 0 | 1 | 05H511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the provider failed to ensure proper documentation of allergies [REDACTED]. Findings include: 1. Review of resident 1's physician's orders [REDACTED]. Review of the resident's medication administration record (MAR) revealed there had been no allergies [REDACTED]. 2. Review of resident 6's physician's orders [REDACTED].>*Iodine. *[MEDICATION NAME]. *IVP dye (used for certain tests). *Ansaids. *Contrast dye. *Sulfa. *[MEDICATION NAME]. *[MEDICATION NAME]. *Cephalizin. *[MEDICATION NAME]. *[MEDICATION NAME]. *[MEDICATION NAME]. *Aerosol spray. Review of resident 6's MAR revealed only the following had been listed as allergies [REDACTED].>*Certrizine and related. *Quinolones. *Sulfonamides. *Ethyl alcohol. The allergies [REDACTED]. 3. Review of resident 7's medical record revealed he had medication allergies [REDACTED]. Review of his February 2013 medication administration record revealed his allergies [REDACTED]. Preceptor: 4. Record review of resident 8's MAR and the physician's recertification orders revealed the medication allergies [REDACTED]. The physician's recertification orders listed [MEDICATION NAME] as an allergy. The MAR listed statins as an allergy. Surveour 5. Interview on 2/14/13 at 8:30 a.m. with the director of nurses revealed the pharmacist listed the allergies [REDACTED].By the time the medication had been recorded on the MAR it had been looked at several times by the pharmacist and nurses. | 2016-10-01 |
| 3681 | 3681 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2013-02-14 | 520 | D | 0 | 1 | 05H511 | Based on record review, policy review, and interview, the provider failed to ensure: *Quarterly quality assurance (QA) meetings were held. *The medical director had been present at least quarterly for the QA meetings. Findings include: 1. Review of the provider's 2/15/12 through 10/31/12 QA meeting minutes revealed the medical director had not attended the 8/1/12 quarterly QA meeting. 2. Review of the provider's QA meeting minutes revealed the last QA meeting had been held on 10/31/12. The QA review had been for 7/1/12 through 9/30/12. There had been no QA meetings since then. 3. Interview on 2/14/13 at 9:00 a.m. with the administrator revealed: *She was not aware the medical director had not attended all of the QA meetings. *She had not attended the 8/1/12 QA meeting. *She stated the next QA meeting was scheduled for 2/27/13. *The next QA meeting had been scheduled for that time due to conflicts in scheduling. Review of the provider's undated quality assurance plan revealed the QA committee would have been composed of the administration, medical staff, QA coordinator, director of nursing, and other department heads. | 2016-10-01 |
| 4946 | 4946 | MENNO-OLIVET CARE CENTER | 435113 | 402 S PINE STREET POST OFFICE BOX 487 | MENNO | SD | 57045 | 2011-04-19 | 281 | E | 0 | 1 | 06HN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure: *Medication (med) documentation was after administration of oral meds for one of one sampled resident (3). *Med documentation was after administration of insulin for three of three sampled residents (1, 9, and 13). Findings include: 1. Observation, interview, and record review on 4/18/11 at 6:05 a.m. in the med room with licensed nurse (LN) A revealed: *A med cup that contained two pills was on top of the med cart. *She informed the surveyor she had set-up resident 3's meds and had already signed the Medication Administration Record [REDACTED] *She had not given resident 3 his meds. Review of resident 3's MAR indicated [REDACTED]. Review of resident 3's narcotic record revealed LN A had signed her initials in the appropriate box for [MEDICATION NAME] sulfate 15 mg, one/half tablet. Interview on 4/19/11 at 8:00 a.m. with the director of nursing (DON) revealed: *She had a nurses meeting on 4/13/11 with employees who administered meds that had included administration of med standards set forth by the South Dakota Board of Nursing that included: -Preparation of the meds. -Administer the meds to the resident immediately. -Watch the resident take the meds. -Sign your name or initials after the resident has taken the meds. *She confirmed that LN A had been at the meeting on 4/13/11. *She agreed the meds should have been signed off after having been administered to the resident. Review of the provider's 5/10/06 Oral Medication Administration policy revealed "Medications are charted, by the administering nurse, by placing their initials in the appropriate box on the medication record after the resident has accepted or refused medication." 2. Observation on 4/18/11 from 6:50 a.m. through 7:15 a.m. revealed: *LN B had gone into the med room and prepared the morning insulin syringes for residents 1, 9, and 13. *After the insulins had been prepared LN B: -Too… | 2014-09-01 |
| 2134 | 2134 | SD HUMAN SERVICES CENTER - GERIATRIC PROGRAM | 43A067 | 3515 BROADWAY AVE POST OFFICE BOX 7600 | YANKTON | SD | 57078 | 2015-12-02 | 221 | E | 0 | 1 | 07B711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to assess three of three sampled residents (1, 3, and 10) for the use of a back closing one-piece outfit. Findings include: 1. Review of resident 3's medical record revealed: *[DIAGNOSES REDACTED]. *A 10/8/15 physician's orders [REDACTED]. *His 11/12/15 care plan had an intervention of (MONTH) wear one-piece outfit prn (as needed) due to disrobing and voiding in inappropriate places. *The (MONTH) personal care record revealed he wore the one-piece outfit twenty-nine out of ninety times. *There was no initial or quarterly assessments for the use of the one-piece outfit. 2. Review of resident 10's medical record revealed: *[DIAGNOSES REDACTED]. *His 10/20/15 care plan had an intervention of One piece outfit all shifts. (Resident name) responds better if you call the one-piece outfit a coverall. *The (MONTH) personal care record revealed he wore the one-piece outfit eighty-nine out of eighty-nine times. *There was no initial or quarterly assessments for the use of the one-piece outfit. 3. Review of resident 1's medical record revealed: *A [DIAGNOSES REDACTED]. *A current signed physician's orders [REDACTED]. *Current care plan intervention dated 4/30/15 (MONTH) use one-piece outfit for dignity AM and PM shifts. Night shift may put on at 4:30 am. *No initial or quarterly assessments for use of the one-piece outfit for dignity. Interview on 12/2/15 at 1:30 p.m. with registered nurse (RN) J confirmed the night shift staff had dressed resident 1 in the one-piece outfit at 4:30 a.m. during final rounds. Day shift staff had removed the one-piece outfit on rounds about 6:30 a.m. when he had dressed for the day. The use in the early morning was to maintain his dignity and had kept him from getting bowel movement all over himself and his room. Surveyor 4. Interview on 12/1/15 at 2:15 p.m. with the director of nursing revealed they had not completed initial or quarterly assessments … | 2019-04-01 |
| 2135 | 2135 | SD HUMAN SERVICES CENTER - GERIATRIC PROGRAM | 43A067 | 3515 BROADWAY AVE POST OFFICE BOX 7600 | YANKTON | SD | 57078 | 2015-12-02 | 246 | D | 0 | 1 | 07B711 | **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 (10) had access to proper footwear. Findings include: 1. Random observations from 11/30/15 through 12/1/15 regarding resident 10 revealed he was not wearing socks or shoes. In the afternoons he wandered in the hall. The lower half of his legs were red and swollen. His feet were also swollen. Review of resident 10's medical record revealed: *[DIAGNOSES REDACTED]. *He was at high risk for falls. *There was no documentation to reflect his choice of not wearing socks or shoes. *On 10/29/15 the physician's assistant had seen him and tried an oral antibiotic for the weeping in his legs. *On 11/10/15 the physician's assistant had examined his legs. *On 11/20/15 the physician had seen him for the possibility of [MEDICAL CONDITION] (infection) in his legs and had determined it was not [MEDICAL CONDITION]. Interview on 11/30/15 at 4:30 p.m. with registered nurse (RN) G regarding resident 10 revealed: *He had worn shoes, but his feet had become so swollen the shoes left imprints on his feet. *His family bought him another pair of shoes, but they were not large enough. *The staff would sometimes put gripper socks on his feet. *She was not sure why he was not wearing them that day. *She thought it had been about a month since his feet had become so swollen his shoes would no longer fit. *He had a history of [REDACTED]. Interview on 12/2/15 at 1:35 p.m. with RN A regarding resident 10 revealed: *His shoes had become too tight for him to wear due to the swelling in his feet. *The doctor had seen him for the swelling. *The social worker (SW) had contacted his family about getting different shoes, but she was unaware of what had happened with that. Interview and record review on 12/2/15 at 1:35 p.m. with SW B regarding resident 10 revealed: *She had documented on 10/13/15 that his shoes had been washed and dried by the staff. -That had … | 2019-04-01 |
| 2136 | 2136 | SD HUMAN SERVICES CENTER - GERIATRIC PROGRAM | 43A067 | 3515 BROADWAY AVE POST OFFICE BOX 7600 | YANKTON | SD | 57078 | 2015-12-02 | 252 | E | 0 | 1 | 07B711 | Based on observation and interview, the provider failed to ensure glassware was provided for meals in three of three residents' units (Spruce One, Spruce Two, and Willow One). Findings include: 1. Observations on 11/30/15 at 5:10 p.m. and again on 12/1/15 at 11:30 a.m. in Spruce One revealed thirteen out of fifteen residents had styrofoam cups for their beverages. Interview on 12/1/15 at 2:15 p.m. with the director of nursing (DON) revealed they should not have been using styrofoam cups for meals. They should have been using glassware. 2. Observations on 11/30/15 on Sruce Two during evening meal, 12/1/15 on Willow One and Spruce Two during noon meal, and on 12/2/15 on Spruce Two during breakfast revealed several residents using styrofoam drinking cups. Interview on 12/2/15 at 8:10 a.m. on Spruce Two with certified nursing assistant (CNA) C and recreational specialist D revealed: *They had used styrofoam drinking cups on Spruce Two for all three meals. *They had requested the kitchen send plastic drinking cups to their unit. Interview on 12/2/15 at 9:35 a.m. with interim food service director E and registered dietitian (RD) F revealed: *RD F thought the food service director had ordered more drinking cups about a month ago. *The plastic drinking cups had been sent to the three geriatric units, but they had not always returned to the kitchen. *They both agreed the syrofoam drinking cups were not homelike, and the residents should have had regular drinking cups. A policy had been requested regarding a homelike environment from the DON but they did not have a policy. Review of the provider's undated Geriatric Program Guidelines revealed As a part of the National Nursing Home Advancing Excellence campaign, we are striving to provide as much of a home-like environment as possible. | 2019-04-01 |
| 2137 | 2137 | SD HUMAN SERVICES CENTER - GERIATRIC PROGRAM | 43A067 | 3515 BROADWAY AVE POST OFFICE BOX 7600 | YANKTON | SD | 57078 | 2015-12-02 | 323 | D | 0 | 1 | 07B711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to thoroughly investigate falls that had resulted in injuries for two of two sampled residents (3 and 6). Findings include: 1. Review of resident 3's medical record revealed: *[DIAGNOSES REDACTED]. *He was at high risk for falls. *He had an unwitnessed fall on 10/14/15. -He had hit his head and was bleeding. *The registered nurse (RN) on duty had documented the fall in the progress notes. *She had not documented the time of the fall, what had been occurring at the time of the fall, who had been working with him, when he had been assisted to the bathroom last, or if the care plan had been followed. *A certified nursing assistant (CNA) had documented the fall in the progress notes. *She had not documented what had been occurring at the time of the fall, who had been working with him, when he had been assisted to the bathroom last, or if the care plan had been followed. *He had falls after that date on 10/23/15, 11/10/15, and 11/22/15. Review of resident 3's 10/14/15 occurrence report revealed there had been no other documentation to support an investigation had been conducted regarding the above fall. 2. Review of resident 6's medical record revealed: *[DIAGNOSES REDACTED]. *He was at risk for falls. *He had an unwitnessed fall on 9/22/15. -He hit his head. *The RN on duty had documented the fall in the progress notes. *During the assessments his head, arms, and legs began to jerk and twitch. *She had not documented the time of the fall, what had been occurring at the time of the fall, who had been working with him, when he had been assisted to the bathroom last, or if the care plan had been followed. 3. Interview on 12/2/15 at 10:45 a.m. with the director of nursing, RN K, RN L, and the Minimum Data Set (MDS) coordinator regarding the falls for residents 3 and 6 revealed: *They had not thoroughly investigated the above mentioned falls. *Without a thorough investigation t… | 2019-04-01 |
| 2138 | 2138 | SD HUMAN SERVICES CENTER - GERIATRIC PROGRAM | 43A067 | 3515 BROADWAY AVE POST OFFICE BOX 7600 | YANKTON | SD | 57078 | 2015-12-02 | 431 | F | 0 | 1 | 07B711 | Based on interview, observation, and policy review, the provider failed to maintain limited access to used Fentanyl (narcotic pain medicine) patch destruction and wasted narcotic pain medication in three of three geriatric (elderly) resident units (Spruce One, Spruce Two, and Willow One). Findings include: 1. Observation and Interview on 12/1/15 at 10:51 a.m. with registered nurse (RN) A in the Spruce One geriatric unit medication room regarding used Fentanyl patch destruction revealed: *The on-campus pharmacy gave the option to either place the patches in a locked box to be returned to pharmacy for destruction, or they could place them in the sharp's box (used to put needles and syringes in). *Those sharp's containers were taken to the admissions department by the unit secretary or the nurse. *Any other narcotic medications that would need to be wasted, for example, if it had been dropped on the floor it would also be placed into the sharps box. Observation and interview on 12/1/15 at 11:10 a.m. with patient services representative M revealed: *Sharps boxes were brought from the units to the admissions office. *There, they were stored under the counter in an unlocked cupboard labeled sharps until they were picked up weekly and taken to the chicken coop (an old chicken coop converted into storage on the property). *To the best of her knowledge that building was not locked or secured. Observation and interview on 12/1/15 at 11:15 a.m. with RN N in the Willow One geriatric unit revealed: *They used the black pharmacy tackle box to return medications back to the pharmacy. *When a used Fentanyl patch was discarded they would place it in that box. *That box was supposed to be returned to the pharmacy that same day if a narcotic medication was known to be in it. *One used Fentanyl patch with a placed-on date of 11/25 was found inside. *That medication was to have been removed after seventy-two hours, so it would have been placed there on 11/28/15. It had not been taken to pharmacy according to their policy. Interview o… | 2019-04-01 |
| 2139 | 2139 | SD HUMAN SERVICES CENTER - GERIATRIC PROGRAM | 43A067 | 3515 BROADWAY AVE POST OFFICE BOX 7600 | YANKTON | SD | 57078 | 2015-12-02 | 441 | D | 0 | 1 | 07B711 | Based on observation, interview, and policy review, the provider failed to use appropriate infection control technique during one of two bathroom observations while toileting one of two residents (16) on contact isolation (specific precautions used when providing care). Findings include: 1. Observation and interview on 11/30/15 during initial tour at the nurses station with registered nurse P confirmed resident 16 was known to have a bacterial infection called ESBL( a bacteria resistant to most antibiotics ) found in his urine. That information had been posted in the nursing station on a whiteboard. Observation on 11/30/15 at 3:10 p.m. of certified nursing assistants (CNA) H and I toileting resident 16 revealed: *Both CNAs had gowned and gloved after sanitizing their hands and proceeded to change resident 16's disposable brief that had become soiled with urine and bowel movement. *CNA I assisted the resident to a standing position from his wheelchair. *CNA H placed a disposable pad on the bed beside the resident, removed his soiled brief, and placed it on that pad. *She got a package of disposable wipes from the cupboard and cleaned his bottom with them. *Her gloves were soiled with bowel movement and urine. *She repeatedly reached into the wipes package and touched the outside of the package each time. *After cleaning the resident she: -Removed her gloves and she: -Reached underneath her protective gown and got the hand sanitizer from her pocket. -Used the hand sanitizer and touched her gown with her hands and placed it back into her pocket. -Put on clean gloves and pulled the resident's pants back up. *With her bare hands she removed her soiled gloves and gown and she: -Washed her hands in the sink, walked to the bed, picking up the soiled brief and pad with her bare hands and placed it in the garbage. *She turned the soiled disposable wipe container to the cupboard. *She reached into her uniform pocket, retrieved her hand sanitizer, used it on her hands and placed it back into her pocket and left the room. Int… | 2019-04-01 |
| 497 | 497 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 550 | D | 0 | 1 | 0CJC11 | Based on observation, interview, record review, and policy review, the provider failed to ensure 4 of 18 sampled residents (10, 19, 20, and 24) were assisted with activities of daily living (ADL) to ensure a dignified life was maintained on a daily basis. Findings include: 1. Observations and record review on 9/17/19 of resident 19 revealed: *His Brief Interview for Mental status assessment score was three indicating he had severe cognitive impairment.*At 9:24 a.m. he had been dressed in blue jeans, white t-shirt, and an unbuttoned black and white flannel shirt.*He had been sitting in his wheelchair (w/c) in his room-His hair appeared greasy and uncombed.*At 9:46 a.m. his blue jeans were soiled from food particles and spills from his morning meal.*At 12:45 p.m. he had been seated in his w/c in the 200 hallway.-Around his mouth were food particles from his lunch meal.-The white t-shirt had brown spills and crumbs of food on the chest area.-The blue jeans had food particles on the thigh area.-There had been a large amount of cookie crumbs in the folds of the lap of his jeans.-His hair still appeared greasy and uncombed.*At 6:15 p.m. he had been seated in his w/c in the 200 hallway.-He and his clothes looked the same as he had at 12:45 p.m.Observation on 9/18/19 at 11:17 a.m. of resident 19 revealed:*He propelled himself in his w/c into the Town Square dining room.*His hair appeared greasy and uncombed.Interview on 9/18/19 at 8:37 a.m. with the director of nursing (DON), the assistant director of nursing (ADON), and the regulatory specialist revealed that part of the process when getting residents up was to complete their ADLs that included hygiene.Interview on 9/18/19 at approximately 11:35 a.m. with certified nursing assistant (CNA) A revealed:*She had taken care of him a little bit that morning.*She had helped him with his pants and shoes. *When questioned she stated she had tried to brush his hair.-He had refused.-She had not documented his refusal yet.Record review on 9/18/19 of resident 19's bathing task and r… | 2020-09-01 |
| 498 | 498 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 573 | D | 0 | 1 | 0CJC11 | Based on interview the provider failed to ensure a request for medical records had been followed-up on in a timely manner for one of one sampled resident (30). Findings include: 1. Interview on 9/18/19 at 10:23 a.m. with resident 30's guardian revealed: *She had been the resident's companion for the past three years. *Recently she had become her guardian due to her son moving to a foreign country. -He wanted someone close by to be able to make decisions. *They were both her guardian. *The resident's son had requested her medical record around 7/26/19. *He had not received it yet. Interview on 9/18/19 at 11:27 a.m., 11:55 a.m., and again at 1:48 p.m. with the administrator revealed: *They had a form for the person requesting the information to sign for a formal request. *They would accept oral requests as well. *The turn around time to get the medical record to the resident or family was twenty-four to forty-eight hours. *The request had been sent to the legal department. *The original request was made by the family on 7/30/19. *They had not sent the medical record, because the legal department was not sure if they could mail the record to a foreign country. *On 9/9/19 the son had given them permission to send the medical record encrypted over e-mail. *As of this interview the medical record had not been sent. *They would send it today. | 2020-09-01 |
| 499 | 499 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 580 | D | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure family and physicians were notified of a change in condition for three of three sampled residents (10, 30, and 74). Findings include: 1. Review of resident 30's medical record revealed on 4/5/19: Bruising was noted to bilateral breasts and around the upper torso of the resident that correlates with the height of the breasts. The nurse assessed the area and noted older bruising that is consistent with a gait belt being on too tightly. They had not notified the family or the physician regarding the bruising. Refer to F600, finding 1. 2. Observation on 9/16/19 at 2:39 p.m. of resident 10 revealed: *She had been laying in her bed sleeping. *The bed had been in a low position and a long mat was laying on the floor next to the bed. *Her pant legs had been pulled half way up her leg to expose the lower part of her ankles and shins. *The posterior part of her left shin had an opened wound on it. *That wound had: -Been opened to air and covered with a dark brown colored scab approximately 1.5 centimeters (cm) by (x) 1.5 cm in diameter. -Reddened skin surrounding the entire outside surface of it. Interview on 9/17/19 at 10:46 a.m. with resident 10's significant other revealed: *He had shown the surveyor the wound on the resident's left shin. *He stated: -They are good at telling us about things but not always. -One day not to long ago it was covered with gauze, but today it is not. -I thought it came from a fall she had not too long ago. *The family had not been notified of the wound located on her left shin. Review of resident 10's medical record from 8/1/19 through 9/18/19 revealed no documentation to support: *How she had acquired a wound on her left shin. *The family or physician had been notified of that wound. Refer to F600, finding 2. 3. Observation on 9/16/19 at 4:36 p.m. of resident 74 revealed: *She had been sitting in a w/c sitting in the unit di… | 2020-09-01 |
| 500 | 500 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 584 | E | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, physical plant and daily inspections manual review, policy review, and job description review, the provider failed to ensure a sanitary and homelike environment was maintained for: *Fourteen of eighteen randomly observed residents' rooms (101, 106, 108, 113, 115, 204, 210, 304, 306, 308, 309, 311, 314, and 403). *Eight of ten randomly observed residents' (3, 10, 19, 31, 48, 60, 71, and 74) wheelchairs (w/c) were clean and in good repair.*Five of ten randomly observed residents' (19, 31, 32, 48, and 60) w/c seat cushions were clean and in good repair. *One of six sampled resident's (23) bed was working properly. *One of three randomly observed whirlpool (w/p) bathing rooms (100 wing) with a restroom area was clean and clutter free. *Two of four dining rooms (Unit and Town Square) were clean and free from leaking water during a storm. *One of one carpeted area in the central supply room that contained multiple resident use items, medication carts, and treatment cart. Findings include: 1a. Observation on 9/17/19 at 8:03 a.m. of room [ROOM NUMBER] revealed: *The floor was sticky to walk on. *The bathroom and closet door frames had multiple gouges leaving bare wood exposed creating uncleanable surfaces. *The floor molding surrounding the room was unclean with a yellowish film on it. *The floor and molding under the sink had unclean matter deposits and dust build-up in the corners. b. Observation on 9/17/19 at 8:15 a.m. of room [ROOM NUMBER] revealed: *Floor molding around the room was unclean with a yellowish film on it. *The area under the sink had built-up unclean matter in the corners and a yellowish film on the floor molding. *The floor molding next the the doorway was loose and had separated from the wall. *The door frames to the bathroom and closet had multiple gouges with bare wood exposed that would not be cleanable. c. Observation on 9/17/19 at 9:15 a.m. of room [ROOM NUMBER] revealed: *Curtains on the win… | 2020-09-01 |
| 501 | 501 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 600 | G | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to appropriately assess, investigate, document, and provide notification to the physician and family for three of three sampled residents (10, 30, and 74) who had injuries from an unknown origin. Findings include: 1. Review of resident 30's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behavioral disturbance. -Pain in right shoulder. -Pain in left shoulder. -Cerebral infarction, unspecified. -Chronic obstructive [MEDICAL CONDITION]. -Anxiety disorder, unspecified. *She had been admitted to hospice on 9/13/19. Review of resident 30's 7/31/19 Minimum Data Set (MDS) assessment coordinator revealed: *She was rarely or never understood. *She sometimes understood others. *She had long and short term memory problems. *She was totally dependent on two staff members for bed mobility and dressing. *She was totally dependent on one staff member for locomotion on and off the unit and for eating. *She required extensive assistance of two staff members for transferring and using the bathroom. *She required extensive assistance of one staff member with personal hygiene. *She did not walk. *She had no swallowing concerns. *She was always incontinent of bladder and frequently incontinent of bowel. The following observations of resident 30 revealed: *On 9/17/19 at 9:41 a.m. she was in a hospital gown sleeping in her bed with music playing in the room. *On 9/17/19 at 12:24 p.m. of resident 30 revealed she was in a hospital gown laying in bed with her eyes opened. -Interview at that time with certified nursing assistants (CNA) L and M revealed since she had gone on hospice she was not getting out of bed or eating. Interview on 9/18/19 at 10:23 a.m. with resident 30's guardian revealed: *On 4/8/19 she had noticed a large bruise around the resident's chest. -It extended over her breasts and around her sides. *S… | 2020-09-01 |
| 502 | 502 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 610 | E | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to appropriately investigate injuries of unknown origin for three of three sampled residents (10, 30, and 74) with bruising and skin concerns. Findings include: 1. Review of resident 30's medical record revealed on 4/5/19: Bruising was noted to bilateral breasts and around the upper torso of the resident that correlates with the height of the breasts. The nurse assessed the area and noted older bruising that is consistent with a gait belt being on too tightly. There was no documentation of a thorough investigation and they had not reported the incident to the SD DOH. Refer to F600, finding 1. 2. Through observation, interview, and review of resident 10's medical record they revealed no documentation to support: *She had a wound on her left shin. *The staff had been aware of the wound on her left shin and how she acquired it. *The family or physician had been notified of that wound. *That anyone had been monitoring and checking on the healing process of the wound. *That an incident report with an investigation was completed to ensure abuse and neglect had not occurred. Refer to F600, finding 2. 3. Through observation, interview, and review of resident 74's medical record they revealed: *On 8/2/19: a skin evaluation had been completed on the resident. -That evaluation confirmed a skin tear to her left forearm. -There was no documentation to confirm the size of the wound and if the family and physician had been notified. -The skin tear had been draining and was covered with a band-aid. *On 8/8/19 a skin evaluation had been completed. -That evaluation confirmed the skin tear to her left forearm and the size of it. -The wound had partial flap loss with no infection or pain during the dressing change. -The physician had been notified and was requested to order a treatment for [REDACTED]. -That had been the first documentation to support physician notification. -N… | 2020-09-01 |
| 503 | 503 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 637 | D | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and manual review, the provider failed to ensure a comprehensive assessment had been completed for two of three sampled residents (20 and 70) who had a change in condition. Findings include: 1. Observation on 9/16/19 at 2:46 p.m. of resident 70 revealed: *The resident's door to her room had been shut. *Upon knocking on the door there was no answer. *Shortly thereafter the resident opened the door and yelled out in a harsh, deep, brogue yeah. -She wanted to know what I was about and just who I was. *She had been walking in her room independently and transferred herself on/off the chair with ease. Interview on 9/16/19 at 2:48 p.m. with certified nursing assistant (CNA) O regarding resident 70 revealed she stated: *She's pretty independent, but you have to watch out for her. *She can be harsh at times and might kick you out of the room. *She stays in her room a lot and is protective of her roommate. *Sometimes she gets upset when you are in there and will cuss, swear, and swing the curtains. *We don't help her with much. Review of resident 70's paper and electronic medical records revealed: *She was admitted on [DATE]. *[DIAGNOSES REDACTED]. *She was hospitalized from [DATE] through 3/8/19 for a fall resulting in a right [MEDICAL CONDITION]. *She had returned on 3/8/19 on skilled nursing services for rehabilitation from a fall resulting in a right [MEDICAL CONDITION] and surgical replacement. *She: -Received physician's orders [REDACTED]. -Had orders to bear weight on her right leg as she could tolerate. -Was to use a positioning wedge between her legs while laying in bed for six weeks. -Required extensive assistance from the staff to ensure all activities of daily living (ADL) had been met. That had included bed mobility, toileting, transfers, personal hygiene, locomotion, and dressing. -Had required limited assistance from the staff for all ADLs and supervision with walking prior to her fall on 3… | 2020-09-01 |
| 504 | 504 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 657 | D | 0 | 1 | 0CJC11 | **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 were updated and revised for one of eighteen sampled resident (20). Findings include: 1. Review of resident 20's medical record revealed: *She had a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. *She had [DIAGNOSES REDACTED]. *She had behavior changes that were identified on 7/18/19 by the behavior committee and were noted in the chart including increased anxiety, agitation, aggression, and crying. Review of resident 20's revised 7/25/19 care plan revealed: *The plan had not included a section for activities of daily living (ADL) or how many staff were required to assist the resident. *There were no interventions listed regarding how to assist the resident when she had challenging behaviors such as aggression or agitation when completing her care. Interview on 9/19/19 at 8:15 a.m. with the Minimum Data Set (MDS) assessment coordinator regarding resident 20's care plan revealed: *She had been responsible for updating the care plans regarding ADLs. *Agreed the care plan should have been updated to include resistive and aggressive behavior. *Stated the nursing staff were also able to update the care plans. Interview on 9/19/19 at 9:14 a.m. with the administrator regarding resident 20's care plan revealed: *He would have expected care plans to have been updated when changes were identified, so staff were aware of the best way to interact with the residents. *His expectation would be the staff members communicated between themselves and informed all interdisciplinary team members regarding changes that had taken place for assisting the residents. Interview on 9/19/19 at 10:01 a.m. with certified nursing assistant (CNA) J regarding resident 20's care revealed: *Whenever changes of residents were identified by the CNAs it was relayed to the charge nurse. *The CNAs communicated with the nursing s… | 2020-09-01 |
| 505 | 505 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 686 | G | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, policy review, and job description review, the provider failed to: *Identify a decline condition and physical capabilities for one of one sampled resident (70) who had a fall with a major injury. *Ensure one of one sampled resident (70) who was at risk for pressure injuries had preventative measures and interventions in place to ensure no skin breakdown had occurred. Findings include: 1. Observation on 9/16/19 at 2:46 p.m. of resident 70 revealed: *The resident's door to her room had been shut. *Upon knocking on the door there was no answer. *Shortly thereafter the resident opened the door and yelled out in a harsh, deep, and brogue voice yeah. -She wanted to know what I was about and just who I was. *She had been walking in her room independently and transferred herself on/off the chair with ease. Interview on 9/16/19 at 2:48 p.m. with certified nursing assistant (CNA) O regarding resident 70 revealed she stated: *She's pretty independent, but you have to watch out for her. *She can be harsh at times and might kick you out of the room. *We don't help her with much. Interview on 9/16/19 at 3:45 p.m. with the director of nursing (DON) revealed she: *Confirmed the resident had behaviors and preferred her independence. *Stated: -She fell a while back and fractured her hip. -She had two deep tissue injuries. -They are facility acquired, but we think they came from the hospital; we did notice the reddened heels but just didn't document it. -Unfortunately they worsened, and she is followed by therapy and the wound nurse. Review of resident 70's paper and electronic medical records revealed: *She was admitted on [DATE]. *[DIAGNOSES REDACTED]. *She had periods of confusion and problems with both short and long term memory recall. *On 3/3/19 she had a fall in her room when attempting to get her suitcase out of the clothes closet. -That fall had resulted in a right [MEDICAL CONDITION] and required admitta… | 2020-09-01 |
| 506 | 506 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 689 | D | 0 | 1 | 0CJC11 | Based on observation, interview, record review, and policy review, the provider failed to ensure gait belts were used appropriately to support safety during stand-pivot transfers for four of nine sampled residents (10, 11, 23, and 24). Findings include: 1. Observation on 9/16/19 at 5:16 p.m. of certified nursing assistant (CNA) K with resident 11 revealed: *CNA K had prepared to assist the resident with a transfer from her bed into a wheelchair (w/c). *She: -Had been awake and was sitting on the edge of her bed. -Required the CNA to assist her with all activities of daily living (ADL) that had included bed mobility and transferring from one surface to another. *CNA K had been: -Standing on the left side of the resident. -Wearing a blue gait belt around her waist. *CNA K: -Placed her right hand under the resident's left upper arm. -Pulled up on that arm and shoulder to move the resident into a standing position. -Guided the resident into the w/c that had been close to the bed by applying pressure on her shoulder. -Took the resident to the bathroom and assisted her with personal care. -Had not attempted to remove her gait belt and put it on the resident to ensure a safe transfer had occurred for her. Review of the 6/27/19 Quarterly Minimum Data Set (MDS) assessment revealed resident 11 needed extensive assistance with bed mobility and transfers. 2. Observation on 9/16/19 at 3:48 p.m. with CNAs O and P with resident 10 revealed: *They had prepared to assist the resident with personal care and transfer into a w/c. *She had been laying in her bed, awake, and making occasional nonsensical statements. *She required the CNAs to assist her with all ADLs. -That had included bed mobility and transferring from one surface to another. *They sat her on the edge of the bed and prepared to transfer assist her with a stand-pivot transfer. *During that transfer they had: -Placed one of their arms underneath her shoulders and grabbed the back of her pants with their other hand. -Pulled the resident up off the bed by applying pressu… | 2020-09-01 |
| 507 | 507 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 690 | D | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure a bowel management program was followed for one of one sampled resident (30) who had gone four to seven days without having a bowel movement. Findings include: 1. Review of resident 30's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behavioral disturbance. -Pain in right shoulder. -Pain in left shoulder. -Cerebral infarction, unspecified. -Chronic obstructive [MEDICAL CONDITION]. -Anxiety disorder, unspecified. *She had been admitted to hospice on 9/13/19. Review of resident 30's 7/31/19 Minimum Data Set (MDS) assessment revealed: *She was rarely or never understood. *She sometimes understood others. *She had long and short term memory problems. *She was totally dependent on two staff members for bed mobility and dressing. *She was totally dependent on one staff member for locomotion on and off the unit and for eating. *She required extensive assistance of two staff members for transferring and using the bathroom. *She required extensive assistance of one staff member for personal hygiene. *She did not walk. *She had no swallowing concerns. *She was always incontinent of bladder and frequently incontinent of bowel. Interview on 9/18/19 at 10:23 a.m. with resident 30's guardian revealed the resident had some issues of constipation and the facility had not done anything about it. Review of resident 30's bowel records from 7/4/19 through 9/19/19 revealed: *She had gone four days without having a bowel movement from 7/29/19 through 8/1/19 and from 8/2/19 through 8/5/19. *She had gone seven days without a bowel movement from 8/23/19 through 8/29/19. *She had gone six days without having a bowel movement from 9/13/19 through 9/18/19. Review of resident 30's nursing progress notes from 7/1/19 through 9/19/19 revealed there was no documentation regarding the above dates and what had been done regardi… | 2020-09-01 |
| 508 | 508 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 812 | D | 0 | 1 | 0CJC11 | Based on observation, interview, and policy review, the provider failed to ensure floors were maintained in a safe and sanitary condition for one of one kitchen. Findings include: 1. Observation on 9/16/19 from 2:18 p.m. to 3:08 p.m. revealed: *The kitchen and storage area floors were unclean with food and dirt particles on them. *The main kitchen floor had a greasy residue and felt slippery to walk on. *The dish room floor had a greasy residue with water covering it which caused it to be very slippery and unsafe. *Wet floor signs had not been placed to alert people to watch their step. Observation on 9/17/19 at 11:11 a.m. revealed the kitchen and dish room floors were unclean with food particles on them and were greasy feeling. *A wet floor sign had not been placed on the dishroom floor to alert people it was slippery. Interview on 9/18/19 at 8:32 a.m. with the dietary manager regarding the unsanitary and unsafe floors revealed: *The cooks were responsible for mopping the kitchen floor in the evening. *The dietary aides doing dishes were responsible to mop the dishroom floor area. *Floors were mopped once a day. *She had a daily assignment sheet for the kitchen staff to sign off on when they had completed their tasks. *The staff had been mopping the floors as assigned. *She thought the floors had been greasy due to a degreaser product they had used. *She agreed the floors had been unsanitary, unsafe, and should have been cleaned more often. Interview on 9/19/19 at 8:34 a.m. with the administrator regarding the kitchen and dishroom floors revealed he: *Would expect the kitchen to be kept clean and sanitary, and the staff to follow their policy and procedure. *Expected the staff to use wet floor signs available to them to avoid fall hazards. Review of the 7/23/14 Nutritional Services policy for floors, tables, and chairs revealed: *The facility will maintain floors, tables and chairs in a clean and sanitary condition to minimize the risk of food hazards. Dining room floors, tables and chairs will be cleaned after … | 2020-09-01 |
| 509 | 509 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 867 | E | 0 | 1 | 0CJC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, policy review, and job description review, the provider failed to put interventions into place to ensure: *Injuries of an unknown origin had been assessed, documented on, and investigated to confirm abuse and neglect had not occurred. *Wound care education to ensure pressure injuries would not have occurred. *Building cleanliness.*Proper cleaning of bathing areas and resident equipment.*An effective performance improvement plan (PIP) was in place.*One of one quality assurance and performance (QAPI) program was proactive and identifying opportunities for improvement. Findings include: 1. Review of the provider's QAPI agenda and minutes dated June, July, and (MONTH) 2019 revealed: *Summary: -Wound care report: -Summarize: New pressure wounds-immediate education for nurses and CNA (certified nursing assistants) how to properly complete skin check/assessment. -Identified Opportunities for Improvement: 1. Bathing Programming. Interview on 9/18/19 at 10:36 a.m. with the executive director revealed: *He had come to the facility on [DATE]. *He oversaw the QAPI program. *His first meeting had been on 8/29/19. *They currently had two ongoing PIPs: -Dietary and gradual dose reduction. *He stated the dietary PIP had been ongoing since at least (MONTH) 2019. -They needed to end the above PIPs. *There had been no feedback on goals. -If what they had been doing was not working they needed to change it. *He realized there were improvements that needed to be made to the program. *Relevant to the QAPI wound care report: -He had been unaware there was to have been immediate education. -He stated he had missed that. -No training had been completed. *They had been unaware of the cleaning issues with the showers, building, and resident equipment.Interview on 9/19/19 at 9:00 a.m. with the director of nursing (DON), assistant director of nursing (ADON), and the corporate regional nurse consultant revealed:*The DON and ADON spent a … | 2020-09-01 |
| 510 | 510 | AVANTARA SAINT CLOUD | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2019-09-19 | 880 | E | 0 | 1 | 0CJC11 | **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: *Three of three certified nursing assistants (CNA) (C, D, and E) knew how to properly disinfect: -The Rushmore Salon and Spa shower area.-The 100 hall bathhouse.*Cleaning had been maintained in two of two bathhouses. Findings include: 1. Observation on 9/17/19 at 11:00 a.m. in the Rushmore Salon and Spa with CNA C revealed:*The salon area was approximately 13 feet by 11 feet.*Approximately 4 inches by four inches of brown and tan tiles covered that floor.*There were two comfort-aire hair dryers that both had smudges of a grease-like material on them.*There was a black, hard, plastic beautician cart on wheels.-There had been a large amount of 1 inch gray light colored pieces of hair covering the top and sides of that cart.*There was a locked, brown cabinet to the right of the hair washing sink.*A faux black and gray marble top had three 2 inch and one 4 inch hard black plastic tube's through it.-Those tubes were used by the beautician to organize her tools.-All three of the two inch tubes were filled approximately one-quarter full with longer hairs.*The west corner of the salon had two dead bugs in a fuzzy gray material resembling dust.*The other corners had also been filled with a gray fuzzy material. *The floor had numerous pieces of gray, black, and white pieces of what appeared to be trash on it. *The baseboard was covered in a white and gray dust like material. *In the shower and tub area:-The black hand soap wall dispenser to the right of the sink was covered in a gray material.-It resembled dust and it was able to be wiped away with the finger.*There was a side enter tub that had a large plastic shower chair in it.2a. Observation and interview on 9/17/19 at 11:17 a.m. with CNA C while she was cleaning the shower area after giving a resident a shower revealed she: *Used a disinfectant cleaner and sprayed the shower chair, railing behi… | 2020-09-01 |
| 1578 | 1578 | MENNO-OLIVET CARE CENTER | 435113 | 402 S PINE STREET | MENNO | SD | 57045 | 2017-01-19 | 278 | D | 1 | 0 | 0GON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, policy review, and manual review, the provider failed to ensure the Minimum Data Set (MDS) assessment had been coded accurately for one of one sampled resident (4) with a restraint. Findings include: 1. Observation and interview on 1/18/17 from 10:00 a.m. through 10:15 a.m. in resident 4's room revealed at: *10:00 a.m. she was asleep in a recliner Broda chair. There was a strap extending over both upper thighs to the back of that chair. *10:15 a.m. she remained in the same position. Interview at that time with registered nurse (RN)/MDS coordinator C revealed the resident: -Had the padded thigh belt on when up in the Broda chair to prevent sliding. -Was unable to release the padded thigh belt. Review of resident 4's medical record revealed: *She had [DIAGNOSES REDACTED]. *A 5/19/16 physician's orders [REDACTED]. Ensure belt is released every 2 hours. *The revised undated care plan revealed she: -Was a high risk for falls related to [MEDICAL CONDITION]'s with chorea movements. -Used a padded thigh belt for positioning in the Broda chair. -Was totally dependent on staff for transferring, dressing, eating, toileting, and personal hygiene. *The 12/1/16 quarterly restraint assessment revealed: -Prompted continued need for restraint: [MEDICAL CONDITION]'s chorea movements, resident is unable to maintain position while in Broda chair. Padded thigh belt need for positoning only while up in Broda chair. -Attempts to reduce restraint use over the past quarter: NA (non-applicable). -The restraint was considered effective. -Interdisciplinary team review summary: Continued need for padded thigh belt while in Broda chair for positioning. Review of the 12/1/16 quarterly MDS assessment revealed: *Brief Interview for Mental Status examination had not been coded indicating severe cognition impairment. *Required: -Extensive assistance with bed mobility. -Total assistance with transfer, locomotion, dressing, eatin… | 2020-01-01 |
| 1579 | 1579 | MENNO-OLIVET CARE CENTER | 435113 | 402 S PINE STREET | MENNO | SD | 57045 | 2017-01-19 | 281 | E | 1 | 0 | 0GON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > [NAME] Based on record review, interview, and policy review, the provider failed to ensure: *One of one sampled resident's (1) fall with injury was reported to the physician or her family. *Professional standards were followed for the assessment and documentation for one of one sampled resident's (2) fall with injury in a timely manner. *An accurate and complete assessment and documentation was done for one of one sampled resident's (8) fall. Findings include: 1. Review of resident 1's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. *She sustained a fall with a head injury on [DATE]. Review of resident 1's [DATE] at 10:35 a.m. incident report revealed: *Unwitnessed fall. *Resident was attempting to shut her door independently while using her walker but fell and hit her head on the dresser. *Certified nursing assistant (CNA) had just left the room but had closed the door per resident. Resident did not put call light on but attempted to shut the door herself even though she needs assist with ambulation. *Resident was assessed by registered nurse (RN) C for injuries with only a 2.0 centimeter (cm) bump on the back of her head. Resident's bump is a small raised area with no skin discoloration. Skin was intact with no bruising or bleeding to area. *There was no documentation the family or physician had been informed of the fall. 2. Review of resident 2's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. *She sustained a fall on [DATE] with head, neck, and hip injuries. *She required an emergency room visit for x-rays of her head, neck, and hip. *There was no documentation in the nursing progress notes at the time of the fall. Review of resident 2's [DATE] at 8:45 a.m. nursing progress notes by RN C revealed: *It was reported to the charge nurse B and this RN by several day shift certified nursing assistants that the resident stated she had a fall in the night and was helped up by three night shift staff.… | 2020-01-01 |
| 1580 | 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 fal… | 2020-01-01 |
| 2645 | 2645 | MEADOWBROOK CARE AND REHABILITATION CENTER | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2015-04-01 | 281 | D | 1 | 0 | 0H8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure physician's orders were followed for one of one sampled resident (1). Findings include: 1. Review of resident 1's medical record revealed:*An 8/20/14 physician's order that daily baths were recommended. *A 10/31/14 physician's order for daily baths with no exceptions. *A 1/5/15 physician's note and order Please re-note order of 10/31 (2014) as to baths and especially the [MEDICATION NAME] order - Pt. (patient/resident 1) advises not being done - This order is to be continuous - DO NOT STOP. Please send me bath log in 30 days to review. *A 2/17/15 physician's note and order ONCE AGAIN - above order and not date to note of 10/31 is NOT being done and the 30 day deal NOT DONE. If not followed and reported to me in 30 days I plan to file a complaint with Social Services - I am not kidding. *A 3/8/15 physician's note and order Bath Daily. Fax me bath record the last 30 days. DON (director of nursing) please call me in AM as to this. Review of resident 1's weekly bathing report for the weeks of 10/29/14 through 3/18/15 revealed: *She had only received daily baths for two weeks of those twenty-one weeks. *Two of those twenty-one weeks had no baths documented. Interview on 3/24/15 at 11:00 a.m. with the west regional transitional leader revealed: *She agreed the above physician's orders had not been followed. *She was aware bathing was an issue. A policy for Physician's Orders had been requested from the west regional transitional leader/RN on 3/31/15 at 5:30 p.m. None was received by the end of the survey. | 2018-04-01 |
| 2646 | 2646 | MEADOWBROOK CARE AND REHABILITATION CENTER | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2015-04-01 | 314 | H | 1 | 0 | 0H8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and pressure ulcer decision making tool, the provider failed to ensure: *One of one sampled resident (2) had not acquired six pressure ulcers (break in skin from continued pressure) after admission to the facility. *One of one sampled resident (2) had not acquired an osteo[DIAGNOSES REDACTED] (infection in the bone) in a pressure ulcer. *One of one sampled resident's (5) pressure ulcer had been identified in a timely manner to prevent further skin damage. Findings include: 1. Review of resident 2's medical record revealed: *She had been admitted on [DATE] with a fracture of her left femur (large bone in thigh). She had no pressure ulcers on admission. *She had additional [DIAGNOSES REDACTED]. *She did not have any preventative measures put in place when she had been admitted . *During her stay she had acquired six pressure ulcers (medial coccyx (center of tailbone), right coccyx (right of the tailbone), left heel, left hip, right iliac crest (top of right hip bone), and left first toe). Those pressure ulcers included: -A stage two (shallow open area of skin) pressure ulcer to her medial coccyx on 4/15/14. It was closed as of 5/13/14 when she readmitted after a hospitalized from [DATE] through 5/12/14. -A stage two admitted pressure ulcer to her right coccyx on 5/13/14. It was healed as of 5/26/14. -She was hospitalized from [DATE] through 6/16/14 and the pressure ulcer to her right coccyx was not present. -The right coccyx pressure ulcer was reacquired on 6/23/14 and was a stage two. There was no record of that pressure ulcer after 6/23/14 when it was open and a stage two. -A stage two pressure ulcer to her left heel on 5/5/14 that healed on 7/14/14. -An unstageable (Full skin thickness tissue loss covered by slough (yellow, tan, gray, green, or brown tissue) and/or eschar (scabbed appearance)) pressure ulcer to her left hip was still present on 3/23/15. -A stage one (Intact skin with redness that does not r… | 2018-04-01 |
| 2647 | 2647 | MEADOWBROOK CARE AND REHABILITATION CENTER | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2015-04-01 | 514 | D | 1 | 0 | 0H8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure complete and accurate documentation was maintained for one of one resident (3) who was discharged against medical advice (AMA). Findings include: 1. Review of resident 3's medical record revealed: *She had been admitted on [DATE] for rehabilitation therapy after a left knee joint replacement. *She was discharged AMA on 9/28/14 at 4:06 p.m. *A release of responsibility for AMA discharge had been signed by her husband and the director of nursing service on 9/28/14. *Review of the interdisciplinary progress notes revealed no documentation resident 3's physician had been made aware of the AMA discharge. *Review of the interdisciplinary progress notes regarding resident 3 also revealed: -She had confusion to time and place. -Required assistance with transfers from wheelchair to other surfaces (bed, toilet, and reclining chair). -Was not able to ambulate independently. -Had a urinary catheter (tube in bladder to drain urine). -Had received narcotic pain medication. -No documentation of why resident 3 discharged AMA. Interview on 4/1/15 at 3:30 p.m. with the interim director of nursing (DON) revealed: *She had not been the DON when resident 3 had been admitted or discharged . *She agreed resident 3's physician should have been notified of her AMA discharge. *She agreed the documentation in the interdisciplinary notes did not reflect why resident 3 had discharged AMA. Review of the provider's 11/12/14 Notification of Change in Resident Health Status policy revealed:*The center would consult the resident's physician when there was a decision to discharge a resident. *The appropriate notification time was listed as immediate. | 2018-04-01 |
| 712 | 712 | FAULKTON SENIOR LIVING | 435084 | 1401 PEARL ST | FAULKTON | SD | 57438 | 2018-11-08 | 657 | D | 0 | 1 | 0HKX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and guideline review, the provider failed to ensure 3 of 18 sampled residents' (8, 33, and 37) care plans matched the needs of the residents. Findings include: 1a. Review of resident 8's last revised 8/27/18 care plan included: *Focus: (Resident name) has impaired skin integrity r/t (related to) immobility and incontinence aeb (as evidenced by) pressure ulcer on left hip and moisture associates (associated) skin alteration on buttocks. *Goal: Resident will be free from skin breakdown through the review date. The review date was 11/25/18. *Interventions: -Diligent peri cares, including barrier cream after incontinent episodes. -Dressings/treatments per orders. -Encourage repositioning q (every) 2-3 hours as needed. -Keep bed linens dry and wrinkle free. -(Resident's name) frequently rolls over to her left hip even after repositioning. Check frequently through the night and repo (reposition) appropriately. -Observe skin during cares. Report any changes to nurse. -Pressure relieving mattress on bed and cushion in chair for prevention of breakdown. Interview on 11/8/18 at 10:00 a.m. with the Minimum Data Set (MDS) coordinator regarding resident 8 revealed she had not: *Made interventions specific to her regarding the turning and repositioning plan. *Included other staff shifts of the resident's always wanting to lay on her left side. *Included the use of the wedge and pillows for positioning. *Included where her actual pressure ulcers had been located. *Included pain interventions related to her impaired skin integrity. *Included what her comfort care included. Refer to F686 finding 1. b. *Focus: (Resident's name) has an ADL (activities of daily living) deficit r/t Alzheimer's and dementia with limited mobility. *Goal: Resident will maintain ability to feed herself with supervision through the review date. The review date was 11/25/18. *Interventions included: -AMBULATION: Unable to ambulate at this… | 2020-09-01 |
| 713 | 713 | FAULKTON SENIOR LIVING | 435084 | 1401 PEARL ST | FAULKTON | SD | 57438 | 2018-11-08 | 686 | G | 0 | 1 | 0HKX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (8 and 15): *Who required staff assistance with care had not developed a facility acquired pressure injury. *Pressure injuries had individualized interventions and implementations in place to prevent facility acquired pressure injuries. *Had received preventative care and treatment for [REDACTED]. Findings include: 1. Observation and interview on 11/06/18 at 12:00 noon with certified nursing assistant (CNA) A and CNA C regarding resident 8 revealed: *She had a pressure relieving air mattress on her bed. *Had a gauze dressing to her left hip. *Stated she liked to lay on her left side. *They would at times find her on her left side after she had been positioned on her right side. *There was a wedge cushion noted in her recliner that was used for positioning in bed. *No cushion was present in her wheelchair. *Stated it started out as a red spot but staff had not kept her off of her left hip, and she had developed a pressure injury. *They were not sure when the pressure injury had started. *They knew it had gotten bigger. Observation on 11/6/18 at 12:11 p.m. revealed resident 8 was seated in her wheelchair in the dining room. No pressure relieving cushion was in her wheelchair. *Prior to the above observation she had been seated in her wheelchair by the front lobby area for approximately twenty minutes before her meal. Observation on 11/6/18 at 2:14 p.m. she was assisted by CNAs A and C to use the toilet. She had not been repositioned since she had used the toilet before lunch. *She was placed in her recliner with the standing lift. There was no pressure relieving cushion in the recliner. *CNA C stated she preferred to sit in her recliner in the afternoon. Observation and interview on 11/07/18 from 8:20 a.m. through 8:28 a.m. with registered nurse (RN) B during a dressing change to the left hip revealed: *An approximately … | 2020-09-01 |
| 2701 | 2701 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 176 | D | 0 | 1 | 0IBE11 | Based on observation, record review, and interview, the provider failed to ensure assessments to self-administer medications were completed quarterly for one of one randomly observed resident (13). Findings include: 1. Observation on 11/17/14 at 5:30 p.m. in the dining room of resident 13 revealed: *Registered nurse (RN) I took her medication from the medication cart and put it into a medicine cup. *She then walked over to her and set the medication cup down in front of her. *She walked away and informed this surveyor that the resident self-administered her medication. Review of resident 13's medical record revealed a self-administration assessment had been completed on 7/24/13 and not again until 10/1/14. Interview on 11/19/14 from 1:10 p.m. through 2:00 p.m. with the director of nursing regarding resident 13 revealed the self-administration assessments should have been done at least quarterly. She agreed they had not been done to that standard. | 2018-04-01 |
| 2702 | 2702 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 221 | E | 0 | 1 | 0IBE11 | Based on observation, record review, interview, and policy review, the provider failed to ensure assessments for all restraints or potential restraints were completed at least quarterly for 4 of 11 sampled residents (1, 3, 4, and 6). Findings include: 1. Observation on 11/17/14 at 2:20 p.m. of resident 6 revealed: *He had a fabric tent over his bed. *The tent zipped close on both sides of his bed leaving the bottom of the bed open. Observation on 11/18/14 at 9:45 a.m. of resident 6 revealed he was in his room sitting in a recliner with a full hand mitt over his right hand. Review of resident 6's 3/7/14 and 11/14/14 Minimum Data Set (MDS) assessments revealed: *He rarely or never was able to make himself understood. *He sometimes had the ability to understand others. *He required total assistance from staff to complete his activities of daily living. *In bed he had a limb and other restraint. *Out of bed he had a trunk and limb restraint. Review of resident 6's 11/6/14 care plan revealed: *Restraints had been identified as a problem area. *The restraints being used had included the following: -Hand mitt. -Posey net bed frame. -Seat belt. Review of resident 6's medical record revealed the last restraint assessment had been completed on 10/21/13. Interview and record review on 11/19/14 from 1:10 p.m. through 2:00 p.m. with the director of nursing (DON) revealed the restraint assessments had not been completed as required. 2. Random observations of resident 1 from 11/17/14 tthrough 11/19/14 revealed when he was in bed a one-half side rail was pulled up on the top half of his bed. Review of resident 1's entire medical record revealed a restraint assessment had been completed on 10/15/13. There had not been one done since. Review of resident 1's 10/23/14 care plan revealed it had not addressed the use of a side rail when he was laid down. Interview on 11/19/14 at 11:50 a.m. with the DON revealed: *She confirmed resident 1 had not had quarterly assessments of his side rail. *A side rail was considered a restraint. *They… | 2018-04-01 |
| 2703 | 2703 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 240 | E | 0 | 1 | 0IBE11 | Based on observation, record review, and interview, the provider failed to ensure two of two sampled dependent residents (6 and 15) were not isolated in their rooms. Findings include: 1. Random observations from 11/17/14 through 11/19/14 of residents 6 and 15 revealed: *They shared a room. *Both residents had difficulty communicating. *They both had feeding tubes. *Neither resident had been taken out of their room for activities during those random observations. a. Review of resident 6's Minimum Data Set (MDS) assessment revealed: *He rarely or never made himself understood. *He sometimes understood others. *He needed total assistance from staff for his activities of daily living. Review of resident 6's 11/6/14 care plan revealed: *Bring out to the day room to watch big TV (television) or out by nurses station so he isn't in his room all day had been discontinued. *Attending at least one activity daily had been discontinued. *There had been no other interventions on the care plan to get him out of his room. b. Review of resident 15's 9/18/14 care plan revealed: *Staff had identified he could not get out of his room without assistance. *The following interventions were in place: -Activity staff to assist him to any activity he wishes to attend. -Enjoys music, animals, news, watches TV in his room, likes to go outside, loves country music, and also uses his own laptop. -Ringo the dog or pet therapy. -1:1 (one-to-one) visiting and 1:1 program done three times weekly. -Family visits often. -Enjoys visiting and joking around with the staff, take outside when possible. -Is able to see out into the hallway when he is in his room and enjoys watching staff, others go by. *No other interventions were in place for taking him out of his room. Review of resident 15's activity attendance documentation revealed: *He is confined to his room most of the time. *(Resident name) requires assistance and planning with nurses to plan for him to attend an activity out of his room or outside. c. Interview on 11/18/14 at 4:00 p.m. with th… | 2018-04-01 |
| 2704 | 2704 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 280 | D | 0 | 1 | 0IBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure 2 of 11 sampled residents' (3 and 5) care plans were reviewed and revised as changes in care needs occured. Findings include: 1. Random observations of resident 5 from 11/17/14 through 11/19/14 revealed she: *Had advanced dementia (confusion and memory loss). *Was unable to voice her needs. *Sat for long periods of time in her Broda chair (special wheelchair). *Continually moved her wheelchair with her feet and moved up and down the halls. *Fidgeted alot. *Had a lap belt restraint on at all times when she was in the chair. *Sometimes took her shoes and socks off. *Was walked with assistance to the dining room table for meals. Review of resident 5's November 2014 Medication Administration Record [REDACTED] *[MEDICATION NAME] (treatment for [REDACTED]. *[MEDICATION NAME] for depression. *[MEDICATION NAME] for dementia. Interview on 11/18/14 at 2:30 p.m. with certified nursing assistants (CNA) F and G and one unidentified CNA regarding resident 5 revealed she: *Was usually very pleasant and loved to sing. *Became very frustrated when she needed to have a bowel movement or if she had an accident with her bowels, and they needed to clean her up. *Sometimes she tried to pick imagined things off the floor. Review of resident 5's behavior documentation revealed from 4/23/14 through 11/19/14: *There were behaviors documented six times. *Those behaviors were restless and fidgeting. *There was no indication her behaviors included combativeness or behaviors that presented a danger to herself or others. Interview on 11/18/14 at 4:00 p.m. with the social services coordinator regarding resident 5 revealed: *The resident became agitated when she had a urinary tract infection [MEDICAL CONDITION]. *Although she was an advocate for the resident, she usually did not question anything the physician ordered to manage the behaviors. Review of resident 5's 9/25/14 care p… | 2018-04-01 |
| 2705 | 2705 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 281 | D | 0 | 1 | 0IBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure: *Physician's orders were obtained for continued care needs on one of one sampled resident (3) who required the use of a Foley catheter (drains urine from the bladder). *Medications given to residents had been on the current physician's orders for two of nine randomly observed residents (13 and 14). Findings include: 1. Review of resident 3's complete medical record revealed he: *Had a [DIAGNOSES REDACTED]. *Had a Foley catheter to assist with the draining of the urine from his bladder. *Had physician's orders requiring the Foley catheter to be changed every month. *Was to have had the Foley catheter changed on 11/17/14. Observation on 11/17/14 at 4:10 p.m. of resident 3 revealed he had no Foley catheter in place. Interview on 11/17/14 at 5:10 p.m. with registered nurse (RN) L revealed: *She had attempted to change resident 3's Foley catheter that morning. *She had met resistance and was unable to re-insert a new Foley catheter. *She had called the physician and received orders to obtain a urine sample for testing. They were concerned he had a urinary tract infection [MEDICAL CONDITION] due to his increase in confusion. *She was waiting on results from the urine sample and further direction from the physician. *He currently had no Foley catheter in place at that time. Review of resident 3's physician's orders dated 11/18/14 [MEDICATION NAME](antibiotic to treat infection) 250 milligrams orally twice a day for seven days. Bladder scan (mechanic device showing how much urine was in the bladder) as needed. The above physicians' orders had not provided: *A [DIAGNOSES REDACTED]. *Direction for when or if the catheter was to be reinserted. *Direction to the nursing staff when using the bladder scan if they should report to the physician on any urine retention. Interview on 11/19/14 at 2:15 p.m. with the director of nursing (DON) revealed she would have expected to fin… | 2018-04-01 |
| 2706 | 2706 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 314 | D | 0 | 1 | 0IBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure interventions were in place and implemented for one of two sampled residents (3) who was at risk for skin breakdown. Findings include: 1. Observation on 11/18/14 from 1:15 p.m. through 4:45 p.m. of resident 3 revealed: *He had: -Been resting in his bed. -Been laying on his back. -Remained on his back during the entire observation time frame. *No staff were observed attempting to reposition him onto his side. Review of resident 3's complete medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He could only be out of his bed four hours a day to promote the healing of the wound. *He was at risk for skin breakdown with a history of pressure ulcers to both of his heels. *He was dependent on the staff to meet all of his mobility needs (transfers and repositioning in bed). Review of resident 3's 8/15/14 significant change Minimum Data Set (MDS) assessment confirmed he was at risk for skin breakdown. He had a pressure relieving device for his bed and wheelchair. He had not been setup for a repositioning program. Review of resident 3's 10/30/14 care plan revealed: *A focus area indicating he was at risk for skin breakdown. *He was dependent upon staff to assist him with bed mobility and transfers. *He had a history of [REDACTED]. *No repositioning program implemented for the staff to follow. Interview on 11/19/14 at 9:25 a.m. with certified nursing assistant E regarding resident 3 revealed: *She confirmed the resident was dependent upon staff to assist him with bed mobility and transfers. *The staff were to have repositioned him every two hours. That was a standard of practice for all residents. Interview on 11/19/14 at 2:30 p.m. with the director of nursing regarding resident 3 revealed: *He was at risk of skin breakdown with a history of pressure ulcers. *She would have expected the MDS coordinator to implement a repositioning program for him … | 2018-04-01 |
| 2707 | 2707 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 323 | D | 0 | 1 | 0IBE11 | Based on observation, interview, and instruction review, the provider failed to ensure four of four randomly observed EZ Way Stands (mechanical lift used for transferring residents) had safety tabs per manufacturer's guidelines. Findings include: 1. Random observations from 11/17/14 through 11/18/14 of four EZ Way Stand mechanical lifts revealed they had no safety tabs attached to the harness attachment area. Those tabs were to ensure the residents would not have fallen from the mechanical lift. Interview on 11/18/14 at 9:45 a.m. with the maintenance supervisor revealed: *He had not been aware all four of the EZ Way Stands were missing their safety tabs. *He had just received a pack of safety tabs in the mail but had not replaced them at the time of this survey. *He did not have a preventative maintenance program in place to routinely check the EZ Way Stands for safety tabs and proper functioning. *The representative for the EZ Stand mechanical lifts did not come to the facility to check the lifts for proper functioning and safety purposes. *He would have relied on the staff to inform him of any concerns regarding the mechanical lifts. *He agreed the residents were at risk for injury with the safety tabs missing from the EZ Way Stands. Review of the provider's EZ Way Stand Operator's instructions revealed: *It is important that certain basic checks be periodically made by maintenance staff to ensure on-going safety throughout the life of the device. *The manufacturer suggests that the following components and operating points be scheduled for inspection at intervals no greater than one month. *Any detected deficiency must be rectified before the stand is put back into service. *Safety tabs needs to be checked to make sure they are in place. | 2018-04-01 |
| 2708 | 2708 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 329 | D | 0 | 1 | 0IBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the provider failed to ensure one of five sampled residents (5) on a [MEDICAL CONDITION] medication (treatment of [REDACTED]. Findings include: 1. Random observations of resident 5 from 11/17/14 through 11/19/14 revealed she: *Had advanced dementia (confusion and memory loss). *Was unable to voice her needs. *Was continually moving her wheelchair with her feet, and fidgeting while moving around the facility. Review of resident 5's November 2014 Medication Administration Record [REDACTED] *[MEDICATION NAME] (treatment for [REDACTED]. *[MEDICATION NAME] for depression. *[MEDICATION NAME] for dementia. Review of resident 5's monthly pharmacy consult reports with recommendations revealed: *8/28/13-Need dx (diagnosis) on [MEDICATION NAME] and [MEDICATION NAME]. The response was Has dx of dementia and anxiety. *9/30/13- Need for psychotic med [MEDICATION NAME]--not anxiety. Add Dementing illness with associated behavioral symptoms. The [DIAGNOSES REDACTED]. *12/17/13- Had to decrease [MEDICATION NAME] to 4.6 milligrams (mg) due to increased anxiety. *11/19/13 Recommend (arrow down/decrease) [MEDICATION NAME] from 25 mg daily to 12.5 mg daily. There was no change made by the physician. *No further recommendations until 8/27/14 and the above 11/19/13 recommendation was repeated. Review of resident 5's 9/23/14 physician's progress note revealed: *(Resident's name) has a history of anxiety and depression. She developed some dementia over the years as well. She is still restless in the evenings and at night. I would not recommend any dose reduction at this time. -That response was nearly one month after the recommendation by the pharmacist. Interview on 11/18/14 at 2:30 p.m. with certified nursing assistants (CNA) F and G and one unidentified CNA regarding resident 5 revealed she: *Was usually very pleasant, and loved to sing. *Became very frustrated when she needed to have a bowel movement or if she ha… | 2018-04-01 |
| 2709 | 2709 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 333 | D | 0 | 1 | 0IBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to correctly follow a physician's order for a blood thinning medication during one of one medication observation (resident 14). Findings include: 1. Observation and interview on 11/18/14 at 7:40 a.m. of registered nurse (RN) J revealed she had prepared 3.5 milligrams (mg) of [MEDICATION NAME] (medication to thin the blood) for resident 14 along with other medications. She informed this surveyor he was to receive 3 mg for two days and then alternate with 3.5 mg every third day. Review of resident 14's 10/7/14 physician's orders revealed the order was for [MEDICATION NAME] 3.5 mg and alt (alternate) every other day with 3 mg. Review of resident 14's 8/5/14 physician's progress note revealed he was receiving [MEDICATION NAME] ([MEDICATION NAME]) 3.5 mg every other day alternate with 3 mg. Interview and record review on 11/19/14 from 10:15 a.m. through 10:45 a.m. with RN K revealed they had been alternating every third day not every other day. Interview on 11/19/14 at 1:10 p.m. with the director of nursing regarding resident 14 revealed: *The original order for [MEDICATION NAME] had been confusing. *The nurses should have clarified the original order. *The physician's order for alternating every other day had not been followed. | 2018-04-01 |
| 2710 | 2710 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 371 | D | 0 | 1 | 0IBE11 | Based on observation, interview, and policy review, the provider failed to ensure appropriate handwashing, glove use, and handling of ready-to-eat food items had been done by two of two observed cooks (C and D) while preparing and serving two of two meals (supper and dinner). Findings include: 1. Observation on 11/18/14 from 5:20 p.m. through 6:00 p.m. of cook D while preparing and serving the supper meal revealed: *She had washed her hands and put on a pair of gloves. With those gloved hands she had performed the following multiple tasks while serving supper: -Removed tin foil from three serving wells. -Touched multiple residents' dietary cards. -Touched two sheets of paper multiple times that contained information on the residents' choices for supper. -Handled and opened two plastic packages containing hamburger buns multiple times to retrieve the buns with her hands. -Hamburgers were placed on those buns and served to the residents for eating. -She had not been observed washing her hands or changing her gloves between any of the above tasks. Observation on 11/18/14 from 11:35 a.m. through 12:00 noon of cook C while serving the dinner meal revealed: *She had opened a plastic bag containing a tray of sandwiches. *She then placed tongs inside of the plastic bag. *She then placed the tongs on top of the plastic bag after placing the first sandwich on a plate for the resident to eat. *She had been observed multiple times retrieving sandwiches from inside of the plastic bag using the tong. After each time she had used the tongs, she placed them on top of the plastic. Interview on 11/18/14 with at the time of the observation with cook C confirmed she had not served the sandwiches in a sanitary manner. The tongs should have been replaced inside of the plastic bag after each use. The outside of the plastic bag had not been considered a clean surface. Interview on 11/19/14 at 10:15 a.m. with the dietary manager revealed: *Cook D should have changed her gloves and washed her hands between each task. *She would have expec… | 2018-04-01 |
| 2711 | 2711 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 441 | D | 0 | 1 | 0IBE11 | Based on observation, interview, and policy review, the provider failed to ensure: *Two of three sampled residents' (1, 3) personal care observations were performed using proper glove use and hand hygiene. *A cleaning policy had been developed for four of four EZ way stand lifts (a mechanical aide to assist in standing residents). Findings include: 1. Observation on 11/17/14 at 4:45 p.m. revealed certified nursing assistants (CNA) G and H went into resident 1's room to get him up for supper. With gloved hands they: *Used the EZ way stand to transfer him into the wheelchair and put him on the toilet in the bathroom. *CNA G removed the resident's incontinent brief (disposable undergarment) and disposed of it in the garbage. *With her soiled gloves she came out of the bathroom, into his room, and obtained a clean brief from his dresser. *They waited until he had finished in the bathroom and brought him out into his room. *They finished tidying up his bed and folded his blanket. *They had not removed their soiled gloves or washed their hands until they were leaving his room. Interview on 11/17/14 at the above time with CNA G revealed she: *Had removed his soiled incontinent brief and threw it away. *Had not removed her gloves at that time or washed her hands. *Should have washed her hands before she went into his dresser and got a clean brief. 2. Observation on 11/18/14 at 8:05 a.m. of CNA M revealed: *She had entered resident 3's room to assist him with getting out of bed. With gloved hands she had: *Pulled his pants and incontinent brief down. *Assisted him to his right side. *Touched his bottom, so this surveyor could observe the wound on his right buttock. *Pulled his pants and incontinent brief back up. *With her soiled gloves she: -Retrieved the EZ Way mechanical lift and his wheelchair. -Used the mechanical lift to transfer him into the wheelchair. -Adjusted his feet on the wheelchair footrests. -Retrieved his hearing aides and placed them in his ears. -Adjusted the bed covers on his bed and replaced the call … | 2018-04-01 |
| 2712 | 2712 | AVERA BORMANN MANOR | 43A137 | 501 NORTH 4TH STREET | PARKSTON | SD | 57366 | 2014-11-19 | 514 | C | 0 | 1 | 0IBE11 | Based on record review, and interview, and job description review, the provider failed to ensure there was supportive documentation by social services and nursing staff to the assessments in the medical record for eleven of eleven sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). Findings include: 1. Review of residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11's entire medical records revealed:*None of the residents medical records had any additional information documented that supported the quarterly, significant change, and annual Minimum Data Sets (MDS) assessments. *Social services had no quarterly documentation. *There was no narrative documentation by the nursing staff that elaborated on the information of the assessments. Interview on 11/18/14 at 4:00 p.m. with the social services coordinator confirmed she had not done any documentation to support the MDS. She only documented interventions as they occurred. Interview on 11/19/14 at 11:50 a.m. with the director of nursing confirmed since they had started the electronic medical records they had quit doing any additional documentation to support the MDS assessments. She was unaware if they had a policy that addressed what was considered a complete medical record. Review of the provider's social services coordinator's job description revealed: Record keeping: Shall keep clear and accurate records. Charting must substantiate reports from the department as well as from the facility. | 2018-04-01 |
| 3272 | 3272 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2014-03-12 | 280 | E | 0 | 1 | 0J1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to revise and review care plans related to identifying non-pharmacological (alternative methods used without medication) interventions and diversional activities for 7 of 14 sampled residents (2, 3, 4, 6, 9, 11, and 12) with pain. Findings include: 1. Review of resident 2's 2/7/14 admission Minimum Data Set (MDS) (document containing health information pertinent to the resident) section J (pain information) revealed: *She had received pain medications within the past five days. *The provider had implemented non-pharmacological interventions. Review of resident 2's current care plan printed on 3/11/14 revealed: *She was at risk for pain. *She had a focus area of pain. *One of the interventions was to Implement non-drug therapies to assist with pain and monitor for effectiveness. *No non-drug therapies had been listed. Review of resident 2's 1/31/14 pain assessment revealed: *She could have been repositioned to help relieve the pain. *No other non-pharmacological interventions had been listed. Review of resident 2's medical record revealed no documentation to support the use of any non-pharmacological interventions to assist with pain management. 2. Review of resident 12's 2/6/14 admission MDS section J revealed: *She had been on scheduled pain medications. *She had received as needed (PRN) pain medications plus the scheduled pain medications during the past five days. *The provider had implemented non-pharmacological interventions. Review of resident 12's current care plan revealed: *She was at risk for pain. *One of the interventions was to Implement non-drug therapies to assist with pain and monitor for effectiveness. *No non-drug therapies had been listed. A PAINAD scale (Pain Assessment in Advanced Dementia Scale) (scale indicating the severity of the resident's pain) had been the only pain assessment used by the provider for the residents. No non-pharmacological pain interventions … | 2017-06-01 |
| 3273 | 3273 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2014-03-12 | 309 | D | 0 | 1 | 0J1L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preceptor: Based on observation, interview, record review, and policy review, the provider failed to report, assess, and intervene for one of four sampled residents (8) with weight loss. Findings include: 1. Review of resident 8's medical record revealed: *He had been admitted on [DATE]. *He was weighed monthly. *His weight on 2/1/14 was 193 pounds (lb). *On 3/4/14 his weight had dropped to 178 lb. *No re-weight had been obtained on 3/4/14. *That would have been a 15 lb weight loss in one month. Random observations of resident 8 on 3/11/14 between 8:00 a.m. and 3:00 p.m. revealed: *He did not speak when spoken to by this surveyor. *He was often found asleep in his room in his wheelchair or bed before and after meals. *He had eaten between 25-50% of his noon meal, but had drank his juice and milk. Interview and record review on 3/11/14 at 2:45 p.m. with the registered dietitian (RD) regarding resident 8 revealed: *She was unaware of the weight decrease for resident 8. She had not reviewed his information yet that month. *The certified nursing assistants (CNA) had from the first day to the seventh of each month to weigh each resident. *The current process had been: -The CNAs weighed the residents as ordered. -The RD reviewed each resident's weight and called the physician with recommendations regarding the increase or decrease in weight. Interview on 3/11/14 at 3:05 p.m. with the RD regarding resident 8 revealed: *She had the CNAs re-weigh him. *His weight had dropped from 178 lb on 3/4/14 to 172 lb on 3/11/14. *Since 2/1/14 (39 days prior to survey date) there had been a total decline of 10.8% of his body weight. *She had notified his physician on 3/11/14 and a dietary supplement was ordered three times daily. Interview and record review on 3/11/14 at 3:20 p.m. with the director of nursing regarding resident 8 revealed: *She was unaware of his weight decline. *She explained the process of weighing residents that included: -The CNAs weighed eac… | 2017-06-01 |
| 3274 | 3274 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2014-03-12 | 371 | E | 0 | 1 | 0J1L11 | Based on observation, interview, and policy review, the provider failed to: *Maintain proper sanitizing of the wiping cloths for dietary staff at two of two meal observations and in two of two kitchens (central kitchen and the Aberdeen dining room's kitchen). *Maintain proper hand hygiene for dietary staff at two of two meal observations and in two of two kitchens (central kitchen and the Aberdeen dining room's kitchen). Findings include: 1. Observation on 3/11/14 at 8:15 a.m. in the central kitchen revealed a wet cloth on the counter laying next to the plates located next to the food steam table area. Observation on 3/11/14 at 11:08 a.m. in the central kitchen revealed a wet cloth on the food production table laying next to a steam table pan and three serving spoons. Observation on 3/11/14 at 11:30 a.m. in the central kitchen revealed a wet cloth on the food counter laying next to the opened Styrofoam cups and packaged crackers. This surveyor observed cook A pick up the wet cloth, and she wiped down the following: *The food steam table counter. *The coffee pot area. *The area around the microwave. *The can opener. *She then placed the same wet cloth on the food counter next to the Styrofoam cups and crackers. Observation on 3/11/14 at 11:35 a.m. in the central kitchen with food service supervisor C revealed she had: *Wiped down a steam table cart with a wet cloth. *Placed the same wet cloth on the cart's handle and pushed the cart out of the central kitchen area down two resident hallways toward the Aberdeen dining room's kitchen. *The wet cloths needed to have been in sanitizing solution when not in use. 2. Observation on 3/11/14 from 11:37 a.m. through 11:45 a.m. with food service supervisor C in the Aberdeen dining room kitchen revealed she had: *Removed the same wet cloth from the steam table cart's handle that she had been holding. *Placed that wet cloth on top of the steam table counter next to the prepared residents' food. *Put her apron on. *Removed the food lids from the steam table with the same wet cl… | 2017-06-01 |
| 3275 | 3275 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2014-03-12 | 468 | D | 0 | 1 | 0J1L11 | Based on observation and interview, the provider failed to have handrails securely attached to the wall in two of five hallways down from nurse station one and nurse station two. Findings include: 1. Observation on 3/11/14 at 6:00 p.m. revealed: *The handrails were loose outside resident rooms 118, 140, 142, 144, 147, 148, 151, 153, and 155. *The handrail outside resident rooms 142 and 144 had pulled away from the wall a quarter inch. *The handrail outside resident room 147 had pulled away from the wall a half inch. *The handrail on the left side of resident room 148 had pulled away from the wall a quarter inch. Observation and interview on 3/12/14 at 2:20 p.m. with the maintenance supervisor revealed: *He agreed the above handrails were loose and not securely attached to the walls. *He had not recently checked the handrails. *There was not a preventative maintenance program for checking the handrails. *They did not have a policy and procedure for checking the handrails. | 2017-06-01 |
| 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 |
| 1861 | 1861 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 166 | E | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, review of resident grievance log, and resident council minutes, and admission packet information review, the provider failed to follow-up with the multiple residents including residents 8, 23, and 24 or family member on grievance concerns. Findings include: 1. Review of the provider's grievance tracking log revealed: *An entry for 7/18/16 Multiple residents not getting baths/showers. -Resolution was adjusted bath schedules and bath audits. -Was documented as resolved on 7/22/16. -Check up on 7/22/16 revealed Satisfied with resolution? Not really. -Additional follow-up needed? Yes. *On 7/25/16 resident 8 had a grievance of Not gotten showers per schedule. -Resolved: Not. -Resolution: Offered showers several times and he refused. -Follow-up: With resident. -Check up date, satisfied with resolution, and additional follow-up questions all had a line drawn through the box. *On 7/27/16 resident 23 had a grievance of No baths per schedule. -Resolution was documented on 8/5/16 as Bath audits and CNA (certified nursing assistant) coaching. -Follow-up: Resident discharged before resolution completed. *On 7/27/16 resident 24 had a grievance No bath since admission. She had been admitted on [DATE]. -Resolution was documented on 7/27/16. -Check up: 7/29/16. Satisfied with resolution: Yes. -Follow-up as needed with resident and son. Review of the (MONTH) and (MONTH) (YEAR) resident council meeting minutes revealed no mention of bathing grievances having been discussed. Review of the bath audit revealed only one audit had been completed on 8/1/16, and revealed six out of eight residents had received their baths as scheduled for that day. There had been no other audits completed. Review of the admission packet given to all residents included a pamphlet entitled Long-Term Care Facilities Resident's Bill of Rights. The pamphlet revealed: *You are entitled to quality of life. A facility must provide care and an environment that contributes… | 2019-08-01 |
| 1862 | 1862 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 223 | J | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and policy review, the provider failed to ensure all residents including resident 10 with cognitive impairment were free from verbal and mental abuse by one registered nurse (RN) (E) and one licensed practical nurse (LPN) (F). NOTICE: On 8/17/16 at 3:15 p.m. notice of immediate jeopardy was given verbally to the administrator and director of nurses (DON). They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were free from abuse. PLAN: During the survey on 8/17/16 at 5:22 p.m. the surveyors confirmed removal of the immediate jeopardy situation. The following is the plan for the removal of the immediate jeopardy. *All residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents have the right to exercise his/her rights. *Initial investigation will be completed immediately by the facility. An Executive Director or Consultant from outside the facility will complete the final investigation. Two nurses involved in the allegations of abuse are suspended effective (MONTH) 17, (YEAR). *All oncoming staff will be re-educated on the Abuse and Neglect Policy and Procedure and the appropriate steps to prevent the occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of resident property and to ensure that all alleged violations of Federal and State law which involve mistreatment, neglect, abuse, injuries of unknown origins, and misappropriation of resident property (alleged violations), Mandatory Reporting, and Caring for Residents with Dementia. *All staff will be re-educated on the Long Term Care Facilities Resident's Bill of Rights provided by the SD Department of Social Services Adult Services and Aging: Ombudsman Program. Leadership: ED, DNS, HRG will receive the education as listed above as well: Elder Justice Acts, Reporting Suspected Crimes Under the Federal Elder Justice Act, and Reporting and Invest… | 2019-08-01 |
| 1863 | 1863 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 225 | J | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and policy review, the provider failed to ensure: *An allegation of abuse for one of one sampled resident 10 with dementia by a registered nurse (RN) (E) and licensed practical nurse (LPN) (F) had been investigated and reported to the South Dakota Department of Health (SD DOH). *An injury of unknown origin for one of one sampled resident (14) who was unable to speak for herself had been documented, investigated, and reported to the SD DOH. Findings include: 1. Review of the providers 11/17/15 Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation policy revealed: *It is the responsibility of all employees to immediately report any alleged violation of abuse, neglect injuries of unknown origin, source and misappropriation of resident property. *It is the policy of this center to take appropriate steps to prevent the occurrence of: -Abuse -Neglect Misappropriation of resident property. *It is also the policy of this center to take appropriate steps to ensure that all alleged violations of federal and state laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violation) are reporting immediately to the executive director of the center. *Such violations are also reported to state agencies in accordance with existing state law. The center investigates each such alleged violation thoroughly and reports the result of all investigations to the executive director or his or her designee, as well as to state agencies as required by state and federal law. * If the suspected perpetrator is an employee or family, friend or visitor the ED (executive director) places the employee on immediate investigatory suspension while completing the investigation. It is explained to the employee that if the investigation results do not require suspension or termination, the employee may be allowed to return to work and any scheduled… | 2019-08-01 |
| 1864 | 1864 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 226 | J | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, and policy review, the provider failed to follow their abuse policies for: *A witnessed event of verbal abuse for one of one sampled resident (10) with dementia by one of one registered nurse (RN) (E) and one of one licensed practical nurse (LPN) (F). *One of one sampled resident (14) who had been unable to speak for herself and had an injury of unknown origin. Findings include: 1. Interview on 8/17/16 at 10:16 a.m. with a certified nursing assistant (CNA) who wished to remain anonymous revealed: *Approximately a couple of weeks ago she had reported resident abuse to the director of nursing (DON). *At approximately 6:00 a.m. regarding that incident the anonymous CNA had observed RN E and LPN F at the end of the west hall. *RN E was screaming hello over and over again at resident 10. *Resident 10 had a [DIAGNOSES REDACTED]. *RN E was mocking what resident 10 was saying. *LPN F was laughing. *The anonymous CNA stated she along with other staff members had reported abuse to the DON and human resources person more than once. *The DON and human resources staff member had laughed at them when they reported abuse. *An anonymous resident had witnessed RN E mocking resident 10 and had reported the abuse to the DON. *An anonymous resident had reported the abuse to the DON. *That morning RN E told staff State is in the building and you all need to be very scared for your jobs. 2. Review of the provider's Protection from Abuse policy revealed All residents in the LivingCenter will be free from verbal, sexual, physical, or mental abuse, neglect, corporal punishment, and involuntary seclusion, according to the outlined in the LivingCenter abuse prevention plan. Refer to F223 and F225. 3. Review of resident 14's medical record revealed: *She had been readmitted on [DATE] from an acute care hospital. *[DIAGNOSES REDACTED]. *On 7/25/16, a skin tear had been identified on her sacral area after she had returned from a trip to the emergency… | 2019-08-01 |
| 1865 | 1865 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 241 | E | 1 | 0 | 0LG211 | > Based on observation, record review, interview, pamphlet review, and policy review, the provider failed to ensure dignity was maintained for six of six sampled residents (2, 4, 7, 13, 19, and 20) who were dependent upon the staff to assist them with activities of daily living (ADL). Findings include: Surveyor: 1. Interview on 8/16/16 at 4:45 p.m. with resident 2 revealed: *Her call light waiting time could be up to an hour. -Usually that happened in the mornings. *She had a wound on her bottom. *Sometimes her bed would be soaked with urine from her catheter leaking. -Staff would tell her they would change her bed when the nurse came in to do her dressing change. -Sometimes staff would change the turning sheet instead of changing all of the bedding. -The last time it had happened was that morning. *Some days she had to lay in bed until 10:30 a.m. -She had asked to get up earlier. -She would have liked to get up between 8:00 a.m. and 9:00 a.m. -She had been told she could not get up until the nurse had come into do her dressing change. *She was told they were short staffed. *She was supposed to have a bath every Tuesday, Thursday, and Saturday. *It had been well over two weeks since she had a bath. Interview on 8/17/16 at 8:05 a.m. with certified nursing assistant assistant G regarding resident 2 revealed: *The resident would like to get up earlier. *They could not get her up for the day until the nurse changed her dressings. *She had observed a couple of nurses just change the turn sheet when the resident's bedding had been soaked with urine. Interview on 8/17/16 at 10:16 a.m. with a CNA who wished to remain confidential revealed LPN F would not change resident 2's sheets when they were wet. Surveyor: 2. Observation and interview on 8/23/16 at 10:22 a.m. with licensed practical nurse (LPN) D regarding resident 2 revealed: *She had gathered supplies and prepared to change a dressing to the resident's buttock. *The resident had refused to have her dressing changed yesterday (8/22/16). *The nurse stated: -I had bee… | 2019-08-01 |
| 1866 | 1866 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 248 | F | 1 | 0 | 0LG211 | > Based on interview, record review, and policy review, the provider failed to ensure an activities program had been actively in-place for 11 of 21 sampled residents (2, 3, 4, 6, 7, 8, 10, 11, 13, 14, and 18's). Findings include: 1. Review of residents 2, 3, 4, 6, 7, 8, 10, 11, 13, 14, and 18's medical records revealed no documentation of activity participation for (MONTH) and (MONTH) (YEAR). Review of the paper records in the activity department revealed minimal activities had been performed for the first seven days of (MONTH) and nothing for (MONTH) 1 through 23, (YEAR). Review of the admission packet given to all residents included a pamphlet entitled Long-Term Care Facilities Resident's Bill of Rights. That pamphlet revealed: *You are entitled to quality of life. A facility must provide care and an environment that contributes to your quality of life including: -A safe, clean, comfortable and home-like environment. -Maintenance or enhancement of your ability to preserve individuality, exercise self-determination and control every day physical needs. Review of the provider's 3/31/16 CMS (Center for Medicare and Medicaid Services) Provision of Activities policy revealed: *In long-term care, an ongoing program of activities refers to the provision of activities in accordance with and based upon an individual resident's comprehensive assessment. Residents in nursing homes need to receive care and/or services to maximize their highest practicable quality of life. However, defining 'quality of life' has been difficult, as it is subjective for each person. Thus, it is important for the facility to conduct an individualized assessment of each resident to provide additional opportunities to help enhance a resident's self-esteem and dignity. *Residents want activities that are relevant and valuable to their quality of life and considered a part of their dignity. Activities need to amount to something and be meaningful to the resident's lives. Residents with dementia are happier and less agitated in homes with many plan… | 2019-08-01 |
| 1867 | 1867 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 280 | E | 1 | 0 | 0LG211 | **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 reflected the current status for 8 of 21 sampled residents (2, 5, 6, 8, 10, 13, 14, and 18). Findings include: 1. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *Admission was for therapy services after a [MEDICAL CONDITION]. *Her Brief Interview for Mental Status (BIMS) testing score indicated she had mild cognitive (thought) impairment. Review of resident 6's 7/1/16 care plan revealed: *She had a history of [REDACTED]. -The care plan for confusion stated to anticipate her needs, and re-orient to the facility as needed. *She had fallen on 7/1/16, 7/9/16, 7/18/16, and 7/21/16. -Interventions had been put in place after the 7/1/16, 7/18/16, and 7/21/16 falls. -Those included reminding the resident frequently to use her call bell or ask for assistance. Review of the provider's Post Fall Analysis/Plan for resident 6 revealed: *A fall occurred on 7/1/16 at 11:15 p.m. The resident explained she was trying to get to her bathroom, but someone had moved her room around. -She had a history of [REDACTED]. -Recommendation/Interventions were Freq (frequent) reminders to call for assistance or use her call light, freq. rounding. -The report indicated the care plan had been revised. --The frequent rounding had not been added to the care plan. *A fall occurred on 7/9/16 at 7:30 p.m. The resident did not explain what she was doing. -She had an impaired safety awareness/judgement. -Possible causal/Contributing factors and observations were garbage can out of resident's reach. -Recommendation/Interventions were Ensure that items are within resident's reach. -The report indicated the care plan was revised. --Items within reach had not been added to the care plan. *A fall occurred on 7/18/16 at 5:20 a.m. The resident's explanation was going to the bathroom. -She had history of falls and impaired safety awareness/judgeme… | 2019-08-01 |
| 1868 | 1868 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 281 | I | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to ensure: *Weekly skin reviews and wound documentation had occurred for 7 of 7 sampled residents (2, 4, 5, 8, 13, 14, and 18). *Physicians' orders were in place for wound treatment for 1 of 6 sampled residents (14). *The correct wound treatment had been completed by 1 of 1 licensed practical nurse (LPN) (D) on 1 of 4 sampled residents (13) who required a daily dressing change for a pressure ulcer. *Physician's order to hold a medication was in the medical record for 2 of 21 sampled residents (2 and 7). Findings include: 1a. Review of resident 13's medical record revealed: *He had been admitted on [DATE]. *[DIAGNOSES REDACTED]. *He had good memory recall. *His blood pressure medication had been discontinued on 8/9/16. *His blood pressure was to have been checked every day. *He had been admitted with multiple wounds. Those wounds had been: -A surgical wound to his left knee. -A stage II pressure ulcer to his coccyx. -A stage II pressure ulcer to his right buttock. -An unstageable pressure ulcer to his right heel. *He had been dependent upon the staff to assist him with activities of daily living (ADL). *Incomplete wound documentation. *A 7/29/16 physician's order for his skin to be assessed weekly. Review of resident 13's weekly skin review sheets from 7/22/16 through 8/10/16 revealed no documentation to support his skin had been assessed after 8/10/16. Those assessments had not been signed or dated by the licensed nurse. Review of resident 13's weekly wound evaluation flow sheets revealed: *On 7/28/16: -The wound on his coccyx had been assessed. -No other wounds had been assessed. *No documentation to support his wounds had been assessed for improvement, worsening, and healing after 7/28/16. *No date or signature from the licensed nurse who had completed the assessment on 7/28/16. Review for resident 13's nurses' progress notes from 7/22/16 through 8/23/1… | 2019-08-01 |
| 1869 | 1869 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 311 | F | 1 | 0 | 0LG211 | > Based on interview, record review, and policy review, the provider failed to ensure a restorative nursing program was in place for all residents living in the facility. Findings include: 1. Review of the provider's 7/21/16 Restorative Guideline policy revealed: *The LivingCenter provides a Restorative Nursing program with interventions that promote the resident's/patient's ability to adapt and adjust to living as independently and safely as possible. *Nursing Rehab/Restorative care includes nursing interventions that assist or promote the resident'/patient's ability to maintain or improve his or her maximum functional status. Review of the admission packet given to all residents included a pamphlet entitled Long-Term Care Facilities Resident's Bill of Rights. That revealed: *You are entitled to quality of life. A facility must provide care and an environment that contributes to your quality of life including: -A safe, clean, comfortable and home-like environment. -Maintenance or enhancement of your ability to preserve individuality, exercise self-determination and control every day physical needs. -Freedom from physical or chemical restraints used for purposes of discipline or convenience. -Freedom from theft of personal property; verbal, sexual, physical or mental abuse; and involuntary seclusion, neglect or exploitation imposed by any one. Review of a list of residents who were receiving skilled therapy services provided by the rehab team leader revealed nineteen of sixty-five residents were receiving skilled therapy services. The other forty-six residents had no programs in place to maintain current physical status. Review of a list provided by the Minimum Data Set nurse indicated twenty-seven residents had impairment with arms or legs. Of those twenty-seven residents, six were receiving skilled therapy services. Surveyor: 2. Interview on 8/23/16 at 9:25 a.m. with the occupational therapist revealed: *She had confirmed there was no restorative programs in place for those residents who were not currently rece… | 2019-08-01 |
| 1870 | 1870 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 312 | E | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and policy review, the provider failed to ensure baths were provided per policy and resident expectation for 13 of 21 sampled residents (1, 2, 3, 4, 6, 7, 8, 9, 10, 13, 15, 16, and 17). Findings include: 1. Review of the provider's 8/16/16 daily certified nursing assistant (CNA) worksheets revealed all residents were to have showers or baths twice weekly. Each resident had designated days and either AM or PM bath times written on those worksheets. 2. Interview on 8/16/16 at 2:50 p.m. with resident 9 revealed she was disappointed she only received one bath per week. She stated she was to receive two baths per week, and she had not been getting that. Interview with her on 8/17/16 at 9:10 a.m. revealed the last time she had a bath was on 8/9/16. She stated she preferred tub baths to showers, but sometimes the tub chair had been broken. At those times she would need to take a shower that she did not like. She stated she was to have had a bath early in the morning before her TED hose were put on. If those were put on before she had received a bath she knew she would not get one that day. Review of resident 9's 7/1/16 through 8/12/16 bathing records revealed she had received during the weeks of: *7/1/16: one tub bath. *7/8/16: two showers. *7/15/16: one shower. *7/22/16: no shower or tub bath. *7/29/16: one shower. *8/5/16: one tub bath. *8/12/16: one shower. For the above seven weeks she should have received fourteen showers or tub baths. She had only received five showers and two tub baths. 3. Interview on 8/18/16 at 9:25 a.m. with resident 1's daughter revealed her mother was to have received baths twice weekly. She stated she knew that was not getting done. She stated she had discussed her concern with the director of nursing and was advised they would take care of it. Review of resident 1's 7/1/16 through 8/16/16 bathing records revealed she had received a tub bath or shower twice weekly until 7/27/16. She … | 2019-08-01 |
| 1871 | 1871 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 314 | H | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to assess, implement interventions, and follow their policy to prevent or ensure worsening of pressure ulcers had not occurred for six of six sampled residents (2, 4, 8, 13, 14, and 18). Findings include: 1. Random observations of resident 13 on 8/22/16 from 4:00 p.m. through 6:20 p.m., on 8/23/16 from 8:00 a.m. through 11:10 a.m., and 1:50 p.m. through 4:00 p.m. revealed: *He been laying in his bed. *He had a pressure relieving air mattress device on his bed. *Head of bed was in the up position. *He had been positioned on his back and down far in the bed. *His right foot/heel had been positioned up against the foot board of the bed. -That foot board was a hard surface. *The back of his right heel and ankle had been positioned directly on the air mattress. -No pressure relieving device (pillows, wedges) was placed underneath that area to ensure no increase in pressure on it had occurred. *He had remained in that position during all the above time frames. Review of resident 13's medical record revealed: *He had been admitted on [DATE]. *[DIAGNOSES REDACTED]. *He had good memory recall. *His blood pressure medication had been discontinued on 8/9/16. *He had been admitted with multiple wounds. Those wounds had been: -A surgical wound to his left knee. -A stage 2 pressure ulcer to his coccyx. -A stage 2 pressure ulcer to his right buttock. -An unstageable pressure ulcer to his right heel. *His 8/2/16 Braden Risk Assessment Scale score had been a 15. -That score made him at high risk for developing pressure ulcers. *He had been dependent upon staff to assist him with activities of daily living (ADL). *A 7/29/16 physician's orders [REDACTED]. *He had been: -Dependent upon staff to assist him with ADLs. -Weak and was working with the therapy department on strengthening. -Having a problem with his blood pressure dropping when he was out of bed for any length of t… | 2019-08-01 |
| 1872 | 1872 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 323 | G | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 2. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *She had fallen five times in July. *Refer to F280, finding 1. 3. Review of the provider's Monthly Event Log revealed: *For (MONTH) (YEAR) there were forty-two resident falls. *For (MONTH) 1 through 16 there were thirteen resident falls. Review of the provider's 8/10/16 Falls Management Guideline policy revealed: *At risk residents are identified through a 'fall alert' communication system to care givers. -During orientation new employees are educated to the fall managment system. *Following a resident's fall: -Appropriate interventions are implemented. -Care plan is updated. *QAPI (quality assurance process improvement) committee minutes reflect data analysis using the information driven by the Quality Control Event Reporting System to identify systemic trends and patterns related to resident falls and appropriate plans of action. *For monitoring/Compliance the following elements are in place for the center to demonstrate satisfactory compliance with the guide: -Residents are evaluated for fall risk. -Communication system to identify the residents at risk for falls. -Residents at risk for falls are care planned with individualized interventions. -The IDT (interdisciplinary team) evaluation is completed on the Change of Condition Report-Post Fall and validation of individualized interventions. Interview on 8/23/16 at 9:10 a.m. with the field services clinical director revealed: *The provider did not have a fall alert communication system. *The Quality Control Event Reporting System was not used to track and trend resident falls. Interview on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director revealed there was no formal activity program. The only activities were provided by volunteers, such as church and bingo. Those activities were not documented in the resident medical record. The activity director had resigned approximate… | 2019-08-01 |
| 1873 | 1873 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 325 | D | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to weigh 2 of 25 sampled residents (14 and 18) according to their policy. Findings include: 1. Observation on 8/22/16 at 4:15 p.m. of resident 14 revealed: *She had been laying in bed sleeping. *She had pressure relieving devices in her bed and in her wheelchair. *She appeared very thin and weak. *Her bones were easily noticed through her skin. Review of resident 14's medical record revealed: *She had been readmitted on [DATE] from an acute care hospital. *[DIAGNOSES REDACTED]. *She had: -No muscle control and required assistance from staff for positioning and transfers. -Required the use of a transfer aide to assist her with transfers in and out of the bed. -Required assistance from staff to get her out of bed once or twice a week per her choice. -Wounds to her sacral area. -Required her fluids to be thickened to nectar consistency. -Been dependent upon staff to assist her with eating. -An 1800 cubic centimeter fluid restriction. *She had been weighed on the 7/5/16 readmission. -She weighed 113.9 pounds. Review of resident 14's 7/20/16 care plan revealed: *Focus area: Swallowing difficulty as related to ALS. *Two goals for that focus area: -Will tolerate food texture and fluid texture and fluid consistency without choking episodes. -Maintain nutritional status and body weight. *Intervention: She should have been weighed monthly. Review of her medical record revealed she had not been weighed since her readmission to the facility on [DATE]. Interview on 8/24/16 at 9:15 a.m. with the Minimum Data Set assessment coordinator and field services clinical director regarding resident 14 revealed: *They confirmed: -The above medical record review. -With the resident's [DIAGNOSES REDACTED]. -Their policy was to weigh residents monthly. -The staff had not weighed her according to their policy and standard. *They agreed she had been at high risk for continued weight … | 2019-08-01 |
| 1874 | 1874 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 328 | E | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, policy review, and record review, the provider failed to ensure oxygen (O2) was provided and maintained continuously for six of six sampled residents (1, 15, 16, 17, and 18) using O2. Findings include: 1. Observation on 8/17/16 at 4:45 p.m. revealed resident 17's portable O2 tank was empty. That was confirmed by a random certified nursing assistant (CNA). The O2 tank was replaced at that time. 2. Interview on 8/18/16 at 9:25 a.m. with resident 1's daughter revealed her mother had a [DIAGNOSES REDACTED]. She had recently been hospitalized from [DATE] through 8/3/16 with pneumonia. On the day she was admitted to the hospital she had been found in her room unresponsive. She was dusky, cold, and had a respiration rate of eight breaths per minute. She was on O2 at 2 liters (L) per minute per nasal cannula (nc). The ambulance and the daughter were called. When the ambulance crew arrived her O2 saturation rates were in the low 80s which was below the recommended rate of 90% or above. She returned from the hospital with a physician's orders [REDACTED]. The daughter stated she came to visit her mother at least once every day. She stated she had come in several times and her O2 was set at 2L. She placed a sign on the back of her mother's wheelchair stating O2 was to be on at 3L. She stated she came in on 8/13/16 and her O2 tank was empty. The O2 flow rate had been set at 1.5 [MI] The CNA who had been working at that time confirmed the O2 tank had been empty. 3. Observation on 8/22/16 at 3:30 p.m. revealed resident 15 had been seated in her wheelchair in her room. Her portable O2 tank was empty. The field services clinical director was notified, and the O2 tank was refilled. The resident was not aware the tank was empty. *Observation on 8/23/16 at 3:50 p.m. revealed resident 15 was seated in her wheelchair in her room. Her portable O2 tank was empty. That tank was immediately refilled by the administrative preceptor. 4… | 2019-08-01 |
| 1875 | 1875 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 353 | I | 1 | 0 | 0LG211 | > Based on interview, schedule review, time card punch records, and policy review, the provider failed to ensure staffing was adequate to provide the necessary care and services for all 65 of the residents. Findings include: 1. Interview on 8/16/16 at 5:00 p.m. with resident 5 revealed there was never enough help. Interview with certified nursing assistant (CNA) G revealed there was a staffing shortage. Residents were not getting their baths because of that staff shortage. Refer to F312. 2. Review of the working nursing schedule revealed Sunday 8/14/16 three of the four scheduled CNAs had called off shift for the 6:00 a.m. until 2:00 p.m. time period. Review of the time card punches for that day revealed one CNA had worked from 6:00 a.m. until 10:00 p.m. There was a light duty CNA on duty from 6:00 a.m. until 9:30 a.m. The director of nursing was written in from 6: 00 a.m. until 3:30 p.m. along with the manager on duty from 7:00 a.m. until 3:30 p.m. 3. Interview on 8/17/16 at 3:30 p.m. with a confidential CNA revealed the administrative staff was in the building but did not assist with resident care. She stated they were on the phone the whole time. Surveyor: 4. Interview on 8/16/16 at 4:45 p.m. with resident 2 revealed: *Her call light times could be up to an hour. *She was told they were short staffed. Refer to F241, finding 1. 5. Interview with an anonymous CNA on 8/17/16 at 10:16 a.m. revealed: *They were short staffed. *There had been only one traveling CNA during the a.m. shift on 8/14/16. *When they were short staffed management will not help them. *Resident 10 always tried to self-transfer, There are not enough staff to watch him. Refer to F323, finding 1. 6. Interview on 8/17/16 at 1:10 p.m. with an anonymous staff member revealed: *They were short on CNAs. *Residents sat in their chairs in the hallways and dining room. -Staff did not come and get them out of the dining room. *Other staff and management could pitch in and help, but they did not. *Residents' hair and hygiene needs were not being met. 7. I… | 2019-08-01 |
| 1876 | 1876 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 441 | F | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and policy review, the provider failed to ensure infection control practices were maintained during: *Dressing changes for four of four sampled residents (2, 13, 14, and 18) by one of one licensed practical nurse (LPN) D. *Personal care for one of one sampled resident (15) by one of one certified nursing assistant (CNA) F. *The storage and removal of soiled linens for one of one sampled resident (21). Findings include: 1. Observation on 8/23/16 at 10:22 a.m. with LPN D during a dressing change for resident 2 revealed: *She had gathered supplies to provide wound care for the resident that consisted of: -A medication cup with medication to be applied to the wounds. -Several unopened 4 by 4 gauze packages. -Three unopened abdominal gauze dressings. -Several gloves removed from a box. -A small tube of normal saline. *Without washing or sanitizing her hands she put on a clean pair of gloves. *While LPN D had her gloves on she: -Adjusted the bed by using the hand control. -Repositioned the resident onto her left side by using the repositioning sheet underneath her. -She had several open wounds to her bottom. Those wounds were not all covered. -There was a significant amount of green/brown colored drainage on that sheet from those wounds. -Adjusted the Foley catheter tubing and drainage bag. -Removed a heavily soiled dressing from her bottom. *She changed her gloves without washing her hands between glove use. *With those gloves on she: -Opened several packages of gauze and laid them on the protective barrier. -Opened the abdominal gauze packages and laid one of the clean dressings directly on top the bed sheet. That area was where the soiled repositioning sheet had been. -Cleansed the wound with the normal saline and several 4 by 4 gauze dressings. *She changed her gloves without washing her hands between glove use. *With those gloves on she: -Applied the medication. -Covered those wounds with the abdominal gauze … | 2019-08-01 |
| 1877 | 1877 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 490 | J | 1 | 0 | 0LG211 | > Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that attained or maintained the highest practicable physical, mental, and psychosocial well-being of all sixty-five residents. Findings include: 1. Interview on 8/17/16 at 3:00 p.m. with the emergency permit holder (EPH) and the director of nursing (DON) revealed they confirmed they were responsible for the overall management of the building. Review of the 10/14/15 EPH job description revealed: *The provider had given to the survey team the Executive Director job description for the EPH job description. *The general purpose of that job was To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives. Serve as a mentor to guide and support all other assigned facilities. Review of the 10/16/14 DON job description revealed the general purpose was to Plan, coordinates, and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality of care that is consistent with company and regulatory standards. Assumes responsibilities of daily operation in the absence of the Executive Director. Interviews, observations, record reviews, and policy reviews throughout the course of the extended survey from 8/16/16 through 8/18/16 and 8/22/16 through 8/24/16 revealed the administration had not ensured all residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being. Refer to F166, F223, F225, F226, F241, F248, F280, F281, F311, F312, F314, F323, F325, F328, F353, F441, and F520. | 2019-08-01 |
| 1878 | 1878 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 493 | J | 1 | 0 | 0LG211 | > Based on observation, record review, interview, and policy review, throughout the course of the survey from 8/16/16 through 8/18/16 and from 8/22/16 through 8/24/16 revealed the governing body had not ensured the safe management and necessary care and services for 65 of 65 residents. Findings include: 1. Review of the last licensure survey completed on 3/3/16 revealed the following deficiencies had been cited: F176, F241, F253, F280, F281, F325, F431, F441, F466, and F520. Review of the complaint survey completed on 7/14/16 revealed the following deficiencies had been cited: F281 and F309. The following had been cited and/or recited (*) for the current survey: F166, F223, F225, F226, *F241, F248, *F280, *F281, F311, F312, F314, F323, *F325, F328, F353, *F441, F490, F493, F501, and *F520. | 2019-08-01 |
| 1879 | 1879 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 501 | J | 1 | 0 | 0LG211 | > Based on interview and job description review, the provider failed to include the medical director in the implementation and/or coordination of residents care in the facility. Findings include: 1. Interview on 8/23/16 at 1:10 p.m. with the medical director revealed he had not been notified until approximately fifteen minutes ago the facility had been in an Immediate Jeopardy situation regarding resident abuse. Review of the 10/14/15 emergency permit holder (EPH) job description revealed: *The provider had given to the survey team the Executive Director job description for the EPH job description. *The general purpose of that job was To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives. According to the Society for Post-Acute and Long-Term Care Medicine (AMDA-American Medical Directors Association) website accessed on 8/24/16 (http://www.paltc.org/amda-white-papers-and-resolution-position-statements/nursing-home-medical-director-leader-manager) revealed there were functions that were relevant for all nursing home medical directors: *Administrative-participates in administrative decision making and recommends and approves relevant policies and procedures. *Professional services-organizes and coordinates physician services and the services provided by other professionals as they relate to patient care. *Quality Assurance and Performance Improvement-participates in the process to ensure the quality of medical care and medically related care, including whether it is effective, efficient, safe, timely, patient-centered, and equitable. *Rights of Individuals-participates in establishing policies and procedures for assuring that the rights of individuals are respected. | 2019-08-01 |
| 1880 | 1880 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 520 | J | 1 | 0 | 0LG211 | > Based on observation, record review, interview, and policy review throughout the survey, the provider failed to ensure an effective quality assurance (QA) program had been maintained to identify concerns, and to develop and implement corrective action. Findings include: 1. Review of the previous complaint survey on 7/14/16 revealed the following deficiencies had been cited: F281, and F309. Review of the recertification survey on 3/3/16 revealed the following deficienies had been cited: F176, F241, F253, F280, F281, F325, F431, F441, F466, F520. During the current survey the following deficiencies had been cited and/or recited (*): F166, F223, F225, F226, *F241, F248, *F280, *F281, F311, F312, F314, F323, *F325, F328, F353, *F441, F490, F493, F501, *F520. The provider did not have a quality assurace or quality assurance process improvement (QAPI) coordinator job description. Interivew on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director confirmed the priior emergency permit holder (EPH) conducted the QA meetings. Unable to interview the EPH due to absent from the second part of the survey. Review of the QA minutes for (MONTH) and (MONTH) (YEAR) revealed: *No tracking and trending of resident falls. *In (MONTH) they had identified concerns with: -Care planning and audits were initiated and continued to find the care plans were not accurate. Refer to F280. -Weights not being completed and stated they found complainace with weights. Refer to F325. -QAPI (quality assurance process improvement) had not included the past survey concerns for weights and infection control. Refer to F441. -Review of the falls that had occured within the facility for May, they were to include a root cause analysis, review of causal factors specific to policy, procedue, people and physical plant. No findings for the above were identified. Refer to F323. *In (MONTH) they had identified concerns with: -Care planning, and audits were initiated and continued to find the care plans were not accurate. Refer to F… | 2019-08-01 |
| 2813 | 2813 | BENNETT COUNTY HOSPITAL AND NURSING HOME | 43A075 | 102 MAJOR ALLEN POST OFFICE BOX 70 | MARTIN | SD | 57551 | 2015-03-04 | 280 | G | 1 | 0 | 0LIG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure care plans reflected the residents' current status for two of seven sampled residents (2 and 3). Findings include: 1. Review of resident 2's medical record revealed he had been admitted on [DATE]. He had developed pressure ulcers after he had been admitted to the facility. His care plan had not been updated in a timely manner to reflect his needs related to the prevention and development of those pressure ulcers. Refer to F314, finding 1. 2. Review of the provider's incident reports revealed resident 3: *On 1/2/15 had fallen from his wheelchair. -Had been propelling himself by pulling himself along using the railing in the hallway. -Had no noted injuries from that fall. *On 2/1/15 had fallen from his wheelchair in the dining room. -Had stood up from the wheelchair and landed on the floor. -Hit his head and received a laceration that required treatment in the emergency room . Review of his medical record revealed he had been admitted on [DATE] with [DIAGNOSES REDACTED]. Review of his nurses notes from 2/1/15 through 3/2/15 revealed: *He had been found on the floor by his bed on 2/9/15. *He had tried to take himself to the bathroom. *He had no injuries from that fall. *An order had been received to use a bed/wheelchair alarm at all times. *The addition of the alarm was due to his increase in falls. *The alarm was placed in the wheelchair. Review of resident 3's 3/2/15 physician's orders [REDACTED]. Review of his last revised on 1/14/15 care plan revealed: *A focus he was at risk for injury related to falls. *The goal had been he would be free from falls through the review date of 4/21/15. *That goal had not been met related to the above fall on 2/1/15. *One of the interventions had been staff were to have discussed the use of a personal safety alarm to alert staff when he attempted to ambulate independently without staff assistance. *The use of that alarm had no… | 2018-03-01 |
| 2814 | 2814 | BENNETT COUNTY HOSPITAL AND NURSING HOME | 43A075 | 102 MAJOR ALLEN POST OFFICE BOX 70 | MARTIN | SD | 57551 | 2015-03-04 | 314 | G | 1 | 0 | 0LIG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to assess, identify, and implement interventions for residents at risk of developing pressure ulcers (injury to skin and tissue from prolonged pressure on it) for one of two sampled residents (2) with pressure ulcers acquired in the facility. Findings include: 1. Review of resident 2's record revealed he had a [DIAGNOSES REDACTED]. Review of resident 2's nurses' notes from 10/29/14 through 1/6/15 revealed he: *Had been admitted on [DATE]. *Had arrived by ambulance on a stretcher. *Had a rash to his groin. *His skin was intact except for the rash in his groin when he was admitted . *Had a feeding tube and oxygen in place. *Was dependent on staff to be re-positioned. *Had been incontinent (unable to control) of bowel and bladder. *Had [MEDICAL CONDITION] (swelling) to his right arm. *On 11/3/14 developed a skin abrasion to his right elbow and a skin abrasion/tear to his coccyx (bottom). *On 11/4/14 needed to be re-positioned. *On 11/24/14 developed a new open area on his right heel with a blister that had ruptured. At that time new orders were received for the use of heel protectors. *On 11/25/14 was rubbing the heel protectors off while in bed. *Was rubbing his feet on the sheets and footboard of the bed. Review of resident 2's certified nurse practitioner (CNP) progress notes dated 11/3/14, 11/11/14, 11/17/14, and 11/24/14 revealed under plan heel and elbow protectors. Review of resident 2's November 2014 treatment record revealed: *Protective dressings were started on 11/3/14 for his coccyx and right elbow. -They were listed as stage II. *An air mattress was to be on the bed starting on 11/3/14. *[MEDICATION NAME] was to be applied to the right heel and covered with a [MEDICATION NAME] dressing every other day. *Heel protectors were to have been on both feet starting on 11/24/14. *Those treatments had started on 11/24/14. Review of resident 2's initial care plan dated … | 2018-03-01 |
| 2815 | 2815 | BENNETT COUNTY HOSPITAL AND NURSING HOME | 43A075 | 102 MAJOR ALLEN POST OFFICE BOX 70 | MARTIN | SD | 57551 | 2015-03-04 | 514 | E | 1 | 0 | 0LIG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure complete and accurate documentation was maintained on: *Care plans for two of seven sampled residents (2 and 3). *Medication administration records (MAR) for three of seven sampled residents (2, 3, and 7). *Treatment administration records (TAR) for one of seven sampled residents (2). Findings include: 1. Review of residents 2 and 3's medical records and care plans revealed their care plans had not been maintained to reflect their current status and care needs. Refer to F280, findings 1 and 2. 2. a. Review of resident 2's January 2015 through February 2015 MARs revealed the following medications had not been documented as given: *January: -[MEDICATION NAME] (heart medication) two times. -[MEDICATION NAME] (blood pressure medication) three times. -Aspirin three times. -[MEDICATION NAME] (heart medication) nine times. -Culterelle capsule (stomach medication) four times. *No reason had been documented for the missed doses. *February: -[MEDICATION NAME] five times. -[MEDICATION NAME] four times. -Aspirin five times. -[MEDICATION NAME] four times. -Culterelle capsule five times. -[MEDICATION NAME] mouthwash fourteen times. *No reason had been documented for the missed doses. b. Review of resident 3's January 2015 through February 2015 MARs revealed the following medications had not been documented as given: *January: -Vitamin D two times. -[MEDICATION NAME] (helps with ability to urinate) two times. -Calcium three times. *No reason had been documented for the missed doses. *February: -Vitamin D four times. -[MEDICATION NAME] three times. -Calcium three times. *No reason had been documented for the missed doses. c. Review of resident 7's January 2015 MAR indicated [REDACTED] *January: -[MEDICATION NAME] (protects the stomach) two times. -[MEDICATION NAME] (controls cholesterol levels) one time. -[MEDICATION NAME] (blood pressure medication) one time. -Multivitamin o… | 2018-03-01 |
| 2816 | 2816 | BENNETT COUNTY HOSPITAL AND NURSING HOME | 43A075 | 102 MAJOR ALLEN POST OFFICE BOX 70 | MARTIN | SD | 57551 | 2015-03-04 | 520 | E | 1 | 0 | 0LIG11 | Based on interview and record review, the provider failed to ensure the quality assurance (QA) program had identified concerns, developed, and implemented effective corrective actions related to care planning and documentation. Findings include: 1. Review of the past three surveys (9/17/14, 9/25/13, and 7/11/12) revealed F280 had been written related to care plans not being updated to meet the residents' needs and conditions. Review of the plan of correction for the 9/17/14 survey revealed: *Twenty five percent of the residents' care plans would be reviewed and updated if needed. *The interdisciplinary team and nursing staff would be educated on the care plan process. *All of the cited residents' care plans were to have been updated. *Findings were to have been reported to QA on a quarterly basis by the director of nurisng (DON). Refer to F280, finding 2. 2. Review of the past three surveys (9/17/14, 9/25/13, and 7/11/12) revealed F514 had been written related to documentation in residents' records that had not been maintained and was cited in 2012 and 2014. Review of the plan of correction for the 9/17/14 survey revealed: *The DON or designee would review the MARs and TARs on a weekly basis to ensure documentation was maintained and accurate. -That would be done for three months and then quarterly thereafter. *Nursing staff would receive education on appropriate and accurate documentation. *Staff identified through the QA process would be further educated. Review of the provider's 11/25/14 QA quarterly meeting minutes revealed: *Accurate documentation related to MARs and TARs had been reviewed. *Thirty-four of thirty-seven reviewed residents' MARs and five residents' TARs were incomplete on 10/19/14 . *Ten of thirty-nine reviewed residents' MARs and one resident's TARs were incomplete on 10/26/14 . *Fifteen of thirty-nine reviewed residents' MARs and two residents' TARs were incomplete on 11/2/14 . *No plan was identified to address the above information for correction or use of the information for QA purposes i… | 2018-03-01 |
| 2783 | 2783 | FIVE COUNTIES NURSING HOME | 435090 | 405 6TH AVENUE WEST | LEMMON | SD | 57638 | 2014-07-24 | 225 | D | 0 | 1 | 0N0O11 | Based on interview, record review, and policy review, the provider failed to ensure two of three sampled allegations by five residents (4, 12, 13, 14, and 15) of abuse and theft of property had been reported to the state reporting agency (South Dakota Department of Health (SD DOH)). Findings include: 1. Review of the provider's file of allegations of abuse or neglect since the previous survey on 6/12/13 revealed an 11/15/13 allegation of abuse against a staff member by resident 12. That allegation had not been reported to the SD DOH prior to the investigation. 2. Review of the same above file revealed an allegation of theft of money by residents 4, 13, 14, and 15. That allegation had not been reported to the SD DOH prior to the investigation. 3. Interview on 7/23/14 at 11:00 a.m. with the social services designee (SSD) revealed she stated she was not aware until the prior two months that allegations of abuse or neglect needed to have been reported to the SD DOH. She stated she contacted the local ombudsman (licensed social worker employed by the South Dakota Department of Social Services) and assumed that individual had reported concerns to SD DOH. She stated she had recently been educated on the need to report all concerns to SD DOH. Interview on 7/23/14 at 3:15 p.m. with the SSD revealed she had misspoken at the earlier interview and was sure she had reported everything to SD DOH. She confirmed no documentation was present to indicate that reporting had occurred. Interview on 7/23/14 at 3:20 p.m. with the SD DOH complaint coordinator confirmed she had no record the above allegations had been reported to her. Review of the provider's revised 9/27/06 Resident Abuse policy revealed: *Allegations of abuse or potential incidents of neglect were to have been reported to the SD DOH within twenty-four hours. *Those twenty-four hours began when the staff member first knew about the event. Review of the provider's November 2010 Social Services Policy Manual's policy on Reporting Abuse to State Agencies and Other Entities… | 2018-03-01 |
| 2784 | 2784 | FIVE COUNTIES NURSING HOME | 435090 | 405 6TH AVENUE WEST | LEMMON | SD | 57638 | 2014-07-24 | 280 | E | 0 | 1 | 0N0O11 | **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 reviewed and revised to reflect the current status for seven of ten sampled residents (1, 4, 5, 6, 7, 8, and 10) related to: *Use of grab bars for four of ten sampled residents (1, 4, 5, and 8). *Preventive skin care for one of ten sampled residents (10). *Use of a pacemaker for one of ten sampled residents (10). *Care of current skin issues for one of ten sampled residents (7). *Activities needed to improve or maintain residents' range of motion (ROM) for three of ten sampled residents (4, 6, and 8). Findings include: 1. Random observations from 7/22/14 at 7:45 a.m. through 7/23/14 at 5:00 p.m. revealed a grab bar on the outside upper edge of resident 1's bed. Review of resident 1's revised 5/8/14 care plan revealed there was no mention of his use of a grab bar for positioning. Interview on 7/24/14 at 7:55 a.m. with the Minimum Data Set (MDS) coordinator revealed she was not aware the use of grab bars should have been included on the care plan. Surveyor 2. Random observation of resident 4's bed from 7/22/14 at 7:45 a.m. and throughout the entire survey revealed there had been grab bars on each side of the upper half of her bed. Review of resident 4's last revised 6/8/14 care plan revealed no mention of those grab bars. 3. Observation on 7/23/14 3:00 p.m. of resident 8 revealed she had a grab bar on the upper half of her bed on the side nearest the closet. Surveyor 4. Observation from 7/22/14 at 7:30 a.m. through 7/24/14 at 8:00 a.m. revealed resident 5 had a grab bar on the outside upper edge of his bed. He was not observed to use the grab bar by this surveyor as he was independent with his transfers. He was sleeping in bed, was in his easy chair, or was in the dining room during all observations of his activity during this survey. Review of his last revised 7/6/14 care plan revealed the use of the grab bar had not been addres… | 2018-03-01 |
| 2785 | 2785 | FIVE COUNTIES NURSING HOME | 435090 | 405 6TH AVENUE WEST | LEMMON | SD | 57638 | 2014-07-24 | 281 | D | 0 | 1 | 0N0O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure professional standards had been followed: *For physician's orders [REDACTED]. *For documentation and care provided by nursing staff in a consistant manner for skin breakdown for one of two sampled residents (7) who had skin breakdown (open wound). *By two of three nurses (registered nurse (RN) E) when signing for medications given during two of three observed medication passes. Findings include: 1. Observation on 7/23/14 at 5:00 p.m. revealed RN F did not wash his hands before putting gloves on. He then set-up supplies on resident 7's bedside table for a dressing change on his back. He cut a clean piece of [MEDICATION NAME] AG (a bacteria inhibiting dressing) to be placed on the resident's open area on his back. He had soaked the [MEDICATION NAME] AG with saline. He then changed his gloves without washing his hands. He removed the soiled dressing from the resident's back. He again changed his gloves without washing his hands. He applied the saline soaked [MEDICATION NAME] AG to the open area on the resident's back and covered it with a [MEDICATION NAME] dressing. He wiped the resident's bedside table off with a dry paper towel when he had removed the soiled items from the table. No barrier had been used for the soiled items when they had been placed on the bedside table. No disinfectant had been used to clean the table. He removed his gloves and left the resident's room with the resident's dressing supply bag. He placed the supply bag back into the medication cart. At that time he cleaned his hands with sanitizer. Review of resident 7's 7/8/14 physician's progress notes revealed a stage II pressure ulceration of the mid-back. It further stated the use of a DuoDerm for the dressing change had kept the ulcer stable but had caused the surrounding tissue to become macerated (the softening and breaking down of tissue caused by prolonged exposure to moi… | 2018-03-01 |
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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 );