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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5067 | 5067 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2011-02-02 | 279 | D | 9LHM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to develop a comprehensive care plan for one of seven sampled residents with [MEDICAL CONDITION] medications (10). Findings include: 1. Review of resident 10's 6/4/10 admission physician's orders [REDACTED]. Further review of the current physician's orders [REDACTED]. Review of resident 10's 6/11/10 admission Minimum Data Set (MDS) revealed he had received an antidepressant every day the last seven days. Review of the [MEDICAL CONDITION] drug use Resident Assessment Protocol (RAP) dated 6/14/10 revealed the [MEDICAL CONDITION] drug use would be addressed on the care plan. Review of the current care plan revealed the [MEDICAL CONDITION] drug use had not been addressed on the care plan. Interview on 2/2/11 at 11:00 a.m. with director of nursing A and director care delivery C confirmed the [MEDICAL CONDITION] drug [MEDICATION NAME] had not been addressed on the care plan for resident 10. They confirmed the RAP decision had been to care plan the [MEDICAL CONDITION] drug use for resident 10. Interview on 2/2/11 at 11:20 a.m. with MDS coordinator D confirmed the [MEDICAL CONDITION] drug use for resident 10 had not been care planned. She stated it must have been missed when the care plan had been completed. She stated sometimes social services added that information regarding the [MEDICAL CONDITION] drug use or the MDS coordinator added it. Review of the provider's care plan policy dated 9/1/05 revealed "A comprehensive care plan is completed within seven (7) days of completion of the comprehensive assessment." | 2014-04-01 | ||
| 5068 | 5068 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2011-02-02 | 371 | D | 9LHM11 | Based on observation, interview, and policy review, the provider failed to ensure all fluids were served in a sanitary manner for all residents who ate in two of two dining rooms. Findings include: 1. Observation on 1/31/11 between 5:45 p.m. and 6:15 p.m. revealed dietary aide G: *Served glasses of juice, water, and milk to the residents in the main dining room. *She frequently placed her hand over the top of the glass. *Her fingers touched the rim of the glass where a resident's mouth would touch when the resident drank from the glass. *She often touched a dining table as she leaned across to set a glass in front of the resident seated on the far side of a table. *She repeated the above procedures numerous times while serving the residents. *After she had finished serving the fluid filled glasses she went into the kitchen. *She returned with several carafes on a cart. *She served coffee and hot chocolate to the residents. *She would pick up a coffee cup fill it with hot water and chocolate powder mix or coffee. *When she placed a cup in front of a resident she touched the rim of the cup with her fingers. *She repeated the above procedures numerous times while serving the residents. 2. Observation on 1/31/11 at 5:20 p.m. revealed dietary aide J while wearing gloves served the residents in the station three dining room. She served the residents their glasses and cups of fluids by grasping the lip rim of the glassware. During that service the dietary aide touched the serving cart, rested her gloved hands on the tops of the tables where residents were sitting, and touched numerous other areas potentially contaminating her gloved hands. 3. Interview on 2/2/11 at 9:50 a.m. with registered dietitian B and food service director E confirmed the dietary aide should not have touched the rims of the glasses and cups. The employee health and safe food handling, safe food handling concepts, and tray set-up and place setting policies dated 4/7/06 were reviewed. They revealed no mention of the proper way to serve fluids without… | 2014-04-01 | ||
| 5069 | 5069 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2011-02-02 | 428 | D | 9LHM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure the consultant pharmacist reported an irregularity of a missed [DIAGNOSES REDACTED]. Findings include: 1. Review of resident 10's 6/4/10 admission physician's orders [REDACTED]. Further review of the current physician's orders [REDACTED]. Review of the medical record revealed no evidence of the physician's documentation for a [DIAGNOSES REDACTED]. Review of the consultant pharmacist's monthly drug regimen review from June 2010 through January 2011 revealed no information regarding a [DIAGNOSES REDACTED]. There was no notification to the physician of the missed diagnosis. Interview on 2/2/11 at 10:40 a.m. with nurse supervisor RN F confirmed there was no documentation from a physician in resident 10's medical record for a [DIAGNOSES REDACTED]. She also confirmed in reviewing the pharmacist's monthly drug regimens for resident 10 there was no documentation the pharmacist had notified the physician of the missed diagnosis. Interview on 2/2/11 at 11:25 a.m. with director of nursing A confirmed there was no physician's documentation of a [DIAGNOSES REDACTED]. Review of the provider's policy for pharmacy drug review dated 9/1/05 revealed: *"A review of the resident's drug regime is completed on a monthly basis by a licensed pharmacist." *"Recommendations and irregularities are reported to the attending physician and the administrative director of nursing services." *"Follow-up to the recommendations is documented." | 2014-04-01 | ||
| 5070 | 5070 | MANORCARE HEALTH SERVICES | 435004 | 400 8TH AVENUE NW | ABERDEEN | SD | 57401 | 2011-02-02 | 441 | D | 9LHM11 | Based on observation, interview, and record review, the provider failed to ensure soiled linen was transported in a manner to prevent the spread of infection for two random observations. Findings include: 1. Observation on 2/1/11 at 9:15 a.m. revealed a staff person was pushing two uncovered wheeled tubs containing soiled linen out of the main dining room. She proceeded down the hallway to the soiled linen room. Observation on 2/2/11 at 9:14 a.m. revealed dietary aide H was pushing two uncovered wheeled tubs containing soiled clothing protectors and tablecloths from the main dining room down the hallway to the soiled linen room. The soiled linens in one of the carts was piled approximately a foot higher than the top of the tub during transport. Interview on 2/2/11 at 9:30 a.m. with laundry supervisor I revealed all soiled linens were to be transported in covered tubs. All tubs for transporting soiled linen had lids. Observation on 2/2/11 at 9:40 a.m. of the tubs in the soiled linen room revealed two empty tubs did not have lids. All of the remaining empty tubs were covered with lids. Interview on 2/2/11 at 9:42 a.m. with director of nursing (DON) A confirmed all tubs should have had covers. All soiled linens and clothing should have been covered for transport. Interview with DON A on 2/2/11 at 10:00 a.m. revealed she had found the lids to the uncovered tubs on the floor in the kitchen. Review of the policy for laundry services dated 6/2/06 revealed: "Soiled linen has been shown to be a source of large numbers of pathogenic organisms. The risk of actual disease transmission is negligible if handled, transported and laundered in a manner that minimizes exposures or contamination and avoids transfer of microorganisms. Techniques minimizing potential nosocomial and occupational risks with soiled linen handling include:... *empty linen containers when three fourths full preventing overflow *secure lids to linen containers prior to transport." | 2014-04-01 | ||
| 5071 | 5071 | GOLDEN LIVINGCENTER - COVINGTON HEIGHTS | 435031 | 3900 S CATHY AVE | SIOUX FALLS | SD | 57106 | 2011-08-17 | 441 | E | 6HI811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure staff followed accepted professional practice standards for infection control for: *Proper handwashing/hand hygiene techniques. *Effective measures to prevent the spread of infections. *Personal care items stored in a sanitary and [MEDICATION NAME] manner. Findings include: 1. Observation on 8/15/11 at 5:30 p.m. of medication (med) pass with licensed practical nurse (LPN) C revealed she: *Entered resident 6's room. *Did not wash her hands. *Put gloves on both hands. *Administered medications through a J-tube (jejostomy). *Administered a nebulizer treatment using the same gloves and did the following: -Opened up the nebule that contained the nebulizer solution. -Placed the solution in the nebulizer. -Administered the nebulizer to resident 6 via the tracheostomy. *She then went over to resident 6's roommate and: -Did not change her gloves or wash her hands. -Placed the oximetry probe on resident 6's roommate's finger. -Obtained the reading. -Removed gloves. *Then exited the room and continued with the medication pass without washing or sanitizing her hands. 2. Random observation on 8/16/11 at 8:02 a.m. of certified nursing assistant (CNA) E revealed she knocked on resident 9's door; the resident was positive for clostridium difficile, she then: *Put on a pair of gloves and a gown. -Entered the room. -Assisted the resident to the bathroom. -Removed the gown and gloves. -Washed her hands in the room. -Then exited the room. Interview on 8/16/11 at 2:20 p.m. clinical care coordinator B revealed: *Personal care razors were sanitized with alcohol after each individual use. *She agreed the razor had not been cleaned. *She agreed the razor should not have been stored in the medication cart. Interview with staff education coordinator F on 8/16/11 at 3:30 p.m. revealed she agreed that staff had not followed the provider's policy and procedures regarding clostridium difficil… | 2014-04-01 | ||
| 5072 | 5072 | GOLDEN LIVINGCENTER - COVINGTON HEIGHTS | 435031 | 3900 S CATHY AVE | SIOUX FALLS | SD | 57106 | 2011-08-17 | 371 | E | 6HI811 | Based on observation, record review, and interview, the provider failed to ensure: *Food thermometers were sanitized prior to use. *The temperature of the food in the pan was checked prior to adding more food to the pan. *The serving cart was properly stored during a fire drill. *The dishmachine temperature log forms were accurately completed. Findings include: 1. Observation on 8/15/11 at 4:55 p.m. revealed cook H : *Was preparing to check the temperature of the foods on the serving cart. *Removed the shield on the stem thermometer. *Poked the stem of the thermometer through the alcohol wipe package. *Left the package on the stem of the thermometer and put the stem in the food item. *Recorded the temperature on the menu. *Removed the alcohol wipe package. *Poked the stem of the thermometer through a second alcohol wipe package and checked the temperature of another food item with the package attached to the thermometer. *Continued the process of poking the thermometer stem through the alcohol wipe package, checking the temperature, and removing the package for the remaining food items. Review of the provider's undated Food Thermometer Guidelines revealed: *Wash, rinse, sanitize, and air-dry the thermometer before each use. A sanitizing mixture or alcohol wipe for food-contact surfaces could be used. *After checking the temperature the thermometer should be washed, rinsed, sanitized, and air-dried. 2. Observation on 8/15/11 at 6:12 p.m. revealed cook I started to add fresh egg salad sandwiches to the pan in the serving cart. There were five sandwiches left in the pan. Temperature check of the five remaining sandwiches by the surveyor revealed the temperature was 60 degrees Fahrenheit. Cook H advised cook I to remove the five sandwiches from the pan. The dietary manager added ice to the pan under the sandwiches. Review of the provider's undated holding and serving policy revealed:*Monitor temperatures of any item being held longer than midway through tray line service to ensure correct temperature was being mainta… | 2014-04-01 | ||
| 5073 | 5073 | GOLDEN LIVINGCENTER - COVINGTON HEIGHTS | 435031 | 3900 S CATHY AVE | SIOUX FALLS | SD | 57106 | 2011-08-17 | 281 | D | 6HI811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preceptor Based on observation, interview, and policy review, the provider failed to ensure: *One of one medications and gastrostomy tube ([DEVICE]) flushes were administered according to accepted standards of clinical practice. *One of forty-five physician's orders [REDACTED]. Findings include: 1. Observation on 8/16/11 at 7:35 a.m. with licensed practical nurse (LPN) G during the medication pass on the revealed: *LPN G was administering eyes drops to resident 16. -Took both bottles of eye drops into resident 16's room. -Placed one bottle of eye drops on the resident's over bed table. -Administered one drop into each eye. *She then obtained the second bottle of eye drops and: -Administered one drop into each eye. -She waited 20 seconds in-between administration of the scheduled eye drops. -She did not wait three to five minutes in between administering the eye drops. 2. Observation on 8/16/11 at 8:10 a.m. with registered nurse (RN) D during the medication pass revealed: *She checked the medication administration record (MAR) for resident 23's order for flushing the [DEVICE]. She then: -Entered resident 23's room. -Washed her hands. -Put on a pair of gloves. -Drew up 30 cc (cubic centimeters) of water. -Inserted the 30 cc of water into resident 23's [DEVICE] with the syringe without first checking the placement of the [DEVICE]. Interview with RN D immediately after the above procedure revealed that placement was not checked on all gastric tubes. Placement was only checked if it is indicated on the physician's orders [REDACTED]. Review of the provider's October 2007 Medication Administration for Enteral Tubes policy revealed: *Verify tube placement. *Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds. 3. Observation on 8/16/11 at 8:15 a.m. during the medication pass with RN D revealed: *Resident 23 had a 8/9/11 order on the MAR for [MEDICATION NAME] 500 milligrams (mg) one cap… | 2014-04-01 | ||
| 5074 | 5074 | GOLDEN LIVINGCENTER - COVINGTON HEIGHTS | 435031 | 3900 S CATHY AVE | SIOUX FALLS | SD | 57106 | 2011-08-17 | 368 | E | 6HI811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to ensure meals were served in a timely manner for two of two meals observed. Findings include: 1. Review of the provider's Dining Services supper meal times revealed: *Villa Dining Room (600 wing) was at 5:00 p.m. *The Pheasant Room (500 wing) was at 5:20 p.m. *Prairie Harvest (100/200 wings) was at 5:45 p.m. *The Pheasant Room (300/400 wings) was at 6:15 p.m. Observation on 8/15/11 revealed the following: *4:55 p.m. Cook H was checking the temperatures of the hot food in the kitchen. *5:10 p.m. The serving cart arrived at the Villa Dining Room. Cook H had to wait for staff to bring him the residents' menus. *5:30 p.m. The serving cart arrived at the Pheasant Room. *6:12 p.m. The serving cart was taken to the kitchen to be replenished. *6:38 p.m. The serving cart was in the Prairie Harvest room. There were no resident menus brought to the serving cart. Staff commented they could not pick-up the menus until the beverage server had served the residents their beverages. The beverage server was observed returning from the kitchen. *6:45 p.m. The service in the Prairie Harvest room was delayed, because they had run out of soup bowls. *7:00 p.m. The serving cart was in the Pheasant Room. *7:18 p.m. The server had run out of soup bowls and side dishes. *7:20 p.m. The last tray was served. Interview on 8/15/11 at 7:20 p.m. with the dietary manager revealed: *Meal service never ran that late. *More dishes were on order. 2. Review of the provider's Dining Services dinner meal times revealed: *Villa Dining Room was at 11:00 a.m. *The Pheasant Room was at 11:20 a.m. *Prairie Harvest was at 11:45 a.m. *The Pheasant Room was at 12:15 p.m. Observation on 8/16/11 revealed the following: *11:07 a.m. The serving cart arrived at the Villa Dining Room. *11:10 a.m. The fire alarm was sounded, and the meal service was interrupted. *11:18 a.m. The first meal was served. A staff person had to r… | 2014-04-01 | ||
| 5075 | 5075 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2011-04-13 | 279 | E | 6FFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preceptor: Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans for 2 of 14 sampled residents (4 and 6): *Were reviewed and revised. *Had appropriate problems, goals, and approaches documented. Findings include: 1. Observation on 4/11/11 from 5:05 p.m. through 5:45 p.m. in resident 4's room revealed: *Resident 4 had been sitting in a recliner in his/her room. -The supper tray had been placed on the bedside table. -The soup and sandwich had been uncovered. *At 5:15 p.m. registered nurse (RN) F entered resident 4's room and approached him/her. *Resident 4 had requested to go to the bathroom. *RN F had assisted resident 4 to the bathroom. *At 5:25 p.m. RN F had assisted resident 4 back to his/her chair. *Resident 4's meal tray remained uncovered. *RN F had asked resident 4 if he/she was going to eat the meal. *Resident 4 refused to eat. *RN F left the resident's room. *Resident 4 remained in his/her chair with the uncovered meal tray placed on the bedside table. *At 5:45 p.m. resident 4 remained in the chair with his/her eyes closed. Observation on 4/12/11 from 10:40 a.m. through 11:15 a.m. revealed: *Resident 4 had been sitting at the dining room table with a meal that consisted of pancakes, scrambled eggs, cold cereal, juice, and tea. * He/she chewed on the one bite of pancake for several minutes. *He/she had 4 natural teeth on the left lower jaw. *He/she had then taken a few bites of scrambled eggs, two bites of pancake, one bite of cold cereal, and a few sips of tea. *At 11:15 a.m. the staff had not offered any assistance to resident 4 during the meal. *Resident 4 had been sleeping off and on at the dining room table. Observation on 4/12/11 from 7:32 a.m. through 7:50 a.m. revealed: *At 7:32 a.m. resident 4 had been sitting in his/her recliner with a banana on a plate and a glass of juice on the bedside table. *At 7:40 a.m. resident 4 had been assisted to the bathroom by RN F. *… | 2014-04-01 | ||
| 5076 | 5076 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2011-04-13 | 176 | D | 6FFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure self-administration of medications was properly monitored for one of two sampled residents (6)who self-administered medications. Findings include: 1. Observation on 4/11/11 at 2:05 p.m. of resident 6's room revealed the night stand next to the door had several pills in a small cup on top of it. Interview on 4/11/11 at 2:06 p.m. with resident 6 revealed: *The pills in the cup were her morning medications. *She was unwilling to state why she had not yet taken the pills. *She stated she thought she might take the pills sometime today. Interview on 4/11/11 at 2:10 p.m. with registered nurse M revealed: *Resident 6's self-administered medications should have been taken by her shortly after being prepared by the nurse. *She assumed the medication on the night stand were her morning medications but could not say for sure. *She agreed the pills found should had been taken early in the morning as she prepared them for the resident around 8:00 a.m. *Resident 6 had been found not to be taking her pills on other occasions. Review of resident 6's entire medical record revealed: *The resident was approved by the care team to self-administer medications. *Medications signed out for that morning were: -[MEDICATION NAME]. -Aspirin. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -[MEDICATION NAME]. -Multivitamin. -[MEDICATION NAME]. -Senna S. -[MEDICATION NAME]-XL. *The nurse was to prepare the medications for the resident to self-administer. Review of the provider's 12/10/10 policy on self-administration of medications revealed: *Nursing staff were to monitor the resident's self-administration of medication. *Self-administration was to be reviewed upon changes in the resident's status. Interview on 4/12/11 at 10:30 a.m. with the director of nursing and the Minimum Data Set coordinator revealed: *They agreed proper self-adminis… | 2014-04-01 | ||
| 5077 | 5077 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2011-04-13 | 323 | E | 6FFB11 | Based on observation, interview, and policy review, the provider failed to ensure one of two first floor, in the west hallway exits to the exterior of the building were properly alarmed. Findings include: 1. Observation and testing on 4/11/11 at 4:30 p.m. of the first floor west hallway exit door closest to the nurses station revealed: *The door had an alarm box in the right upper corner. That box had a key activated on and off switch. *The alarm on the door had been turned off. *Testing of the door revealed no alarm sounded when opened. Once through the door direct access to a river and a street were available. *No wandering system was in place for that door. *No staff monitored that door. *Multiple residents passed through that hallway on a day-to-day basis. Observation and testing on 4/12/11 at 7:30 a.m. and at 4:45 p.m. of the first floor west hallway exit door closest to the nurses station revealed the status of the alarm was unchanged since the initial observation. Interview on 4/12/11 at 4:50 p.m. with registered nurse G revealed she: *Agreed the door alarm had been turned off. *Agreed the door was to be alarmed at all times. *Was unsure why the alarm had been turned off. Interview and policy review on 4/13/11 at 9:50 a.m. with the director of nursing revealed: *That door was to be alarmed at all times. *The provider's safety policy revised on 10/12/10 called for that door to have been alarmed. *She agreed having that door alarm turned off was a safety risk to the first floor residents. | 2014-04-01 | ||
| 5078 | 5078 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2011-04-13 | 309 | D | 6FFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical well being for two of five sampled residents (8 and 14) who had no recorded bowel movement (BM) for four or more days. Findings include: 1. Review of resident 8's 4/5/11 resident progress notes revealed she had: *Not had a BM since 3/30/11. *Poor food intake as well. *A flat abdomen. *Not answered when asked if she felt she needed to have a BM. *Poor fluid intake the previous night. *No acute distress. Review of resident 8's April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *There had been no as needed medication (PRN) administered to the resident on 4/5/11. *There were no PRN medications ordered for bowel elimination until 4/12/11 when an order was received for a [MEDICATION NAME] suppository to be given PRN for constipation. Review of resident 8's vital sign report revealed there were no documented BMs from: *3/30/11 to 4/5/11 (6 days). It was noted the BM on 4/5/11 was soft and formed. *3/16/11 to 3/21/11 (5 days). It was noted the BM on 3/21/11 was soft and formed. *2/13/11 to 2/18/11 (5 days). It was noted the BM on 2/18/11 was dry and hard. There was no documentation on the February 2011 and March 2011 MARs that a prn medication for bowels had been given. 2. Review of resident 14's vital sign report revealed there were no documented BMs from 3/31/11 to 4/3/11 (4 days). There was no documentation that PRN medication for constipation had been given. Review of resident 14's March 2011 MAR indicated [REDACTED] *10 milligrams [MEDICATION NAME] suppository. *30 milliliters Milk of Magnesia. Review of resident 14's 1/27/11 care plan revealed: *Constipation was listed in the [DIAGNOSES REDACTED]. *There were no problems or goals related to constipation on the care plan. Interview on 4/12/11 at 4:58 p.m. with nurse coordinator J … | 2014-04-01 | ||
| 5079 | 5079 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2011-04-13 | 441 | D | 6FFB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure infection control policies were followed for one of one sampled resident (1) with a Multi-Drug Resistant Organism (MDRO). Findings include: 1. Review of resident 1's admission sheet revealed he: *Was admitted on [DATE] from the hospital. *Had a [DIAGNOSES REDACTED]. Review of resident 1's 3/28/11 Minimum Data Set revealed a MDRO was not coded as an active diagnosis. Interview with licensed practical nurse B on 4/11/11 at 5:00 p.m. revealed she was unsure if resident 1 had a MDRO of the nares. Observation on 4/11/11 at 3:00 p.m. of resident 1's room revealed a sign in bold print posted on the outside of the door that read: *Contact precautions were to be followed and included: -A private room. -To wear gloves. -To wear a gown if the person entering aniticpated contact with the resident or environmental surfaces. -To limit the transport of the resident from the room. Review of 3/15/11 laboratory (lab) records revealed a MDRO screen was completed of his nares (nose) and on a wound. The results were positive. Review of resident 1's physician's progress notes from 3/22/11 through 4/12/11 revealed: *The physician had seen him eight times. *The MDRO had not been addressed in any of the progress notes. *There was not any evidence of discussion of the treatment for [REDACTED]. Interview and review of the medical record on 4/12/11 at 8:30 a.m. with infection control nurse (ICN) A revealed: *She was unaware resident 1 had been transferred to the transitional care unit (TCU). *She was unaware of the current status of resident 1 and the treatment of [REDACTED]. *She verified resident 1 had been there for three weeks. *It was the provider's protocol throughout their entire health system to: -Inform her when there was a resident admitted with an infectious disease. -Follow the provider's protocol for the specific MDRO resident 1 had. -That protocol included a re… | 2014-04-01 | ||
| 5080 | 5080 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2011-04-13 | 253 | D | 6FFB11 | Based on observation and interview, the provider failed to: *Schedule the cleaning of the isolation room to prevent potential cross-contamination. *Maintain the following items in a sanitary manner: -The refrigerator at the first floor nurses station. -The windows of the activity room. -The floor of the supply room located in the back of the maintenance area. Findings include: 1. Observation on 4/12/11 at 1:30 p.m. in the transitional care unit (TCU) revealed: *An environmental services staff person was cleaning rooms. *Resident room 3521 had isolation precautions. Interview on 4/12/11 at 1:30 p.m. with environmental staff person O revealed: *She was the person responsible for cleaning the rooms in the TCU. *She was aware one room was an isolation room. *She cleaned the room as part of the normal rotation and did not clean it last. *She was not aware she should have cleaned the isolation room last. Interview on 4/12/11 at 1:40 p.m. with the infection control nurse revealed isolation rooms should have been cleaned last. Interview on 4/12/11 at 2:15 p.m. with the head of environmental services revealed isolation rooms should have been cleaned last. Review of the 5/2010 policy and procedure for cleaning isolation rooms did not mention isolation rooms were to be cleaned last. 2. Observation on 4/13/11 at 9:03 a.m. of the refrigerator at the first floor nurses station revealed: *Spilled liquids in the bottom drawer of the refrigerator (Photo 3). *Spilled liquids below the bottom drawer of the refrigerator (Photo 2). *The vent panel located under the refrigerator door was covered with food debris (Photo 2). Interview on 4/13/11 at 9:03 a.m. with the head of environmental services revealed she thought the dietary department would be responsible for keeping the refrigerators clean. Interview on 4/13/11 at 9:05 a.m. with several unidentified staff people working in that area revealed the night shift were responsible for cleaning the refrigerator. No specific answers were given as to who on the night shift was responsible … | 2014-04-01 | ||
| 5081 | 5081 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2011-04-13 | 364 | D | 6FFB11 | Surveyor: NELSEN, TRAVIS Based on interview and testing, the provider failed to prepare and serve palatable food to residents who dined in their rooms. Findings include: During group interview on 4/12/11 at 12:10 p.m. two random residents expressed concerns about the quality of food they received on the trays delivered to their rooms. One resident resided in the transitional care unit and the other on the first floor of the main building. Both residents stated the food was usually cold when delivered to their rooms. Surveyor: CHRISTENSEN, SUSAN Precepter: 2. Interview on 4/12/11 at 12:10 p.m. with resident 4's family revealed the food was usually cold when it was delivered to the resident's room. *A temperature and palatability test tray on 4/13/11 at 10:30 a.m. by surveyor revealed: *The temperature of the ham patty was 117 degrees Farenheit. *Food should have been hot held at or above 135 degrees Farenheit until served. *The ham was tasteless. | 2014-04-01 | ||
| 5082 | 5082 | CLARKSON HEALTH CARE | 435037 | 1015 MT VIEW RD | RAPID CITY | SD | 57702 | 2011-02-10 | 441 | E | SQV011 | Based on observation, interview, policy review, and record review, the provider failed to ensure: *The chemicals and process used to sanitize all of the laundry was effective against drug resistant organisms. *The chemical used to sanitize the whirlpool tub was applied effectively during the cleaning process. *Two of four hopper spray hoses were stored correctly to prevent cross-contamination. Findings include: 1. Observation on 2/9/11 at 7:55 a.m. in the laundry revealed: *Bacstat liquid softener by Ecolab was used in the laundry as a sanitizer. *Bacstat was listed on a chart on the wall by the wash machines for use in the comingled loads. Interview on 2/9/11 at 7:59 a.m. with laundry aide C confirmed: *He did not know which chemical was the sanitizer used in the laundry for the comingled clothing. *He did not know what organisms the Bacstat was effective against. *He further stated administrator A had all of that information. Interview on 2/9/11 at 4:15 p.m. with administrator A confirmed: *She did not know what organisms the sanitizing chemical Bacstat liquid softener from Ecolab used on the comingled laundry was effective against. *The water temperature used for the comingled laundry was 90-120 degrees Fahrenheit. *The water temperature was not hot enough to sanitize the laundry. *She was not able to receive a current information sheet from the chemical supplier that identified what Bacstat was effective against. Review of the provider laundry procedure dated 8/2006 revealed there was no information that directed which chemical was to be used for sanitizing the comingled laundry. 2. Interview on 2/9/11 at 2:40 p.m. with certified nursing assistant (CNA) H confirmed: *She had applied the Mastercare disinfectant to the tub and tub chair surfaces for one to two minutes usually before she rinsed the tub/chair surfaces. *She had never left it on for more than 5 minutes. Interview on 2/10/11 at 7:38 a.m. with CNA I confirmed he sprayed the Mastercare disinfectant on the tub surfaces and left it on for two to three … | 2014-04-01 | ||
| 5083 | 5083 | CLARKSON HEALTH CARE | 435037 | 1015 MT VIEW RD | RAPID CITY | SD | 57702 | 2011-02-10 | 520 | F | SQV011 | Based on interview, record review, and policy review, the provider failed to use the quality assurance process in an effective manner to resolve the extended response times for call lights for 5 of 12 sampled residents (4, 5, 9, 11, and 12) and 2 of 4 random residents (14 and 15)that had been identified. Findings include: 1. Interviews with random and sampled residents and families from 2/7/11 through 2/10/11 confirmed the staff response time to answer call lights was too long. Refer to F241. 2. Review of staff meeting minutes revealed: *Certified nursing assistant (CNA) meeting minutes dated 3/17-18/10 addressed call lights were not answered for up to 20 to 47 minutes. *The time of those call lights not being answered usually occurred during staff break times in the morning or from 7:00 p.m.-8:00 p.m. in the evening. *CNA meeting minutes dated 7/8/10 addressed complaints from families in regards to answering of call lights. *One family complained the call light had been on for 45 minutes, and the resident had needed to use the toilet. *CNA meeting minutes dated 10/14/10 addressed call light complaints had been received again from families. *The minutes further stated the call light had been on for over 20 minutes, and staffing that shift consisted of three nurses, a medication aide, and six CNAs. Interview on 2/9/11 at 4:45 p.m. with director of nursing (DON) B confirmed: *She had been aware of the lengthy time it took for call lights to be answered. *She had considered it to be an ongoing problem that had not been solved. *She expected the call lights to be answered in 15 minutes or less. *There was no policy that addressed the answering of call lights. *She had not used the Quality Assurance process to address the lengthy call light response concerns presented by families and residents. Interview on 2/9/11 at 5:10 p.m. with administrator A confirmed: *The DON had not submitted any written reports to the quality assurance committee that addressed the answering of call lights. *The quality assurance committee no… | 2014-04-01 | ||
| 5084 | 5084 | CLARKSON HEALTH CARE | 435037 | 1015 MT VIEW RD | RAPID CITY | SD | 57702 | 2011-02-10 | 241 | E | SQV011 | Based on interview and record review, the provider failed to create an environment that ensured dignity was maintained for 5 of 12 sampled residents (4, 5, 9, 11, and 12) and 2 of 4 random residents (14 and 15) evidenced by the extended staff response time to residents' call lights. Findings include: 1. Phone interview on 2/8/11 at 8:25 p.m. with resident 5's son confirmed: *He was disappointed with the care his mother received. *It had been difficult to find staff at times when they were visiting. *He would wait a long time for the call light to be answered after it had been put on for his mother. *Eventually he would have to go look for staff and would find them in another wing. Review of resident 5's electronic call light usage record for December 2010 and January 2011 revealed the following times that were over 15 minutes in duration: *On 12/29/10 at 12:39:29 p.m. it took 34.4 minutes for her call light to be answered. *On 1/8/11 at 9:38:32 a.m. it took 16.6 minutes for her call light to be answered. *On 1/31/11 at 7:17:02 p.m. it took 21.1 minutes for her call light to be answered. 2. Interview on 2/10/11 at 10:30 a.m. with resident 11 revealed: *It had taken as long as an hour and a half for the call light to be answered at times. *She had turned the call light off herself at times, as she grew tired of waiting for staff to answer the call light. *She felt there had not been enough staff available to answer call lights at those times. *There had been no shift that had taken longer than another to answer her call light. *The staff stated they had been in another wing at the times when she had waited a long time for a response. Review of resident 11's electronic call light usage record for December 1, 2010 through February 8, 2011 revealed the following times that were over 15 minutes in duration: *Nine occurrences for the month of December 2010 that were over 15 minutes and up to 46.0 minutes in duration for the staff to have answered her call light. *Thirteen occurrences for the month of January 2011 that w… | 2014-04-01 | ||
| 5085 | 5085 | CLARKSON HEALTH CARE | 435037 | 1015 MT VIEW RD | RAPID CITY | SD | 57702 | 2011-02-10 | 371 | E | SQV011 | Based on observation, interview, and policy review, the provider failed to ensure food safety and sanitary practices were used for: *Labeling and dating of thawed liquid supplements in the refrigerator. *Handwashing and glove use between tasks during two of two meal service observations to prevent cross-contamination. Findings include: 1. Observation on 2/7/11 at 5:00 p.m. revealed: *A plastic box containing 48 thawed Mighty Shake supplements in the small refrigerator in the kitchen. *Five more thawed Mighty Shakes sat on the shelf next to the plastic box. *Each Mighty Shake container stated the supplement was only good for fourteen days after thawing. *None of those thawed Mighty Shake containers were marked with a thaw date. Interview at the above time with dietary chef E and dietary aide F revealed Mighty Shakes were removed from the freezer and placed in the refrigerator every day. They further revealed the supplements were usually used within one week of removal from the freezer. Observation from 2/8/11 at 4:40 p.m. through 2/9/11 at 8:30 a.m. revealed: *The above plastic box continued to hold between twenty and forty-four thawed Mighty Shakes. *There was still one of the five above thawed shakes on the shelf beside the box. It had been pushed all the way to the back of the refrigerator and out-of-sight. Interview with dietary manager (DM) D on 2/9/11 at 8:30 a.m. confirmed: *The provider used alot of Mighty Shakes every day. *The thawed Mighty Shake supplements were only good for fourteen days after being thawed. *None of those Mighty Shake cartons or the plastic box of supplements had the thaw date written on them. *The thawed Mighty Shakes should have been dated when they had been removed from the freezer to ensure they were used within the fourteen days. 2. Observation of the brunch service on 2/8/11 from 11:00 a.m. through 12:00 noon revealed dietary chef G washed his hands and put on clean gloves. With those gloved hands he touched the dietary cards and the individual menus filled out by each resident.… | 2014-04-01 | ||
| 5086 | 5086 | GOLDEN LIVINGCENTER - ARLINGTON | 435050 | 120 CARE CENTER ROAD POST OFFICE BOX 280 | ARLINGTON | SD | 57212 | 2011-01-05 | 281 | D | ZPLO11 | Based on observation, interview, and record review, the provider failed to ensure one of three nurses (C) followed professional standards when providing medications to the residents during 19 of 20 opportunities during medication pass and 6 random observtions following the medication pass observation . Findings include: 1. Random observation on 1/4/11 from 7:20 a.m. to 1:00 p.m. revealed nurse C for 19 of 20 observed medications set-up the medications, documented on the medication administration records (MAR), and then proceeded to give the medication to the residents. Interview on 1/5/11 at 7:35 a.m. with nurse C revealed the nurse nodded in agreement that: *Documentation should have occurred after the residents had taken the medication. *She had completed the documentation prior to giving the medications to the residents. Interview on 1/5/11 at 10:00 a.m. with director of nursing B revealed the nurses were to document the medications after they were taken by the resident. Review of the provider's policy and procedure for Medication Administration dated September revealed "The individual who administers the medication dose, records the administration on the resident's MAR (medication administration record) following the medication being given." Review of the South Dakota Board of Nursing statement dated 10/17/06 revealed "It is the position of the South Dakota Board of Nursing that the standard for safe administration of medication includes the practice of documenting medication following administration to the patient." Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, p. 847, revealed "After administering a medication, the nurse records it immediately on the appropriate record form. The nurse never charts a medication before administering it." | 2014-04-01 | ||
| 5087 | 5087 | GOLDEN LIVINGCENTER - ARLINGTON | 435050 | 120 CARE CENTER ROAD POST OFFICE BOX 280 | ARLINGTON | SD | 57212 | 2011-01-05 | 323 | D | ZPLO11 | Based on observation, interview, record review, and policy review, the provider failed to ensure gait belts were used consistently by staff to transfer residents for three of four transfers observed. Findings include: 1. Observation on 1/4/11 at 8:35 a.m. revealed certified nurse assistants (CNA) D and E: *Transferred resident 2 from a wheelchair (w/c) onto the toilet by: -Placing their arms under the resident's shoulders. -Lifting the resident's total body weight as he/she did not stand. -Using the resident's slacks to help hold him/her up and pivoted onto the toilet. *After the resident was finished on the toilet: -CNA D took the resident's hand and helped him/her stand. -Then as the CNAs redressed the resident he/she began to bend his/her knees and did not stand up. -The CNAs placed their arms under the resident's shoulders and lifted the resident back into the w/c. *After the resident was back in the w/c the CNAs again placed their arms under the resident's shoulders to assist him/her to slide back in the w/c. *Resident 2 was taken to the lounge and transferred into a recliner chair by using the same technique of placing their arms under the resident's shoulders and lifting him/her. *A gait belt/transfer belt was not used to transfer the resident. 2. Observation on 1/4/11 at 4:10 p.m. two random CNAs transferred resident 2 from a recliner chair by the nursing station by placing their arms under his/her shoulders and lifting the resident into a Merri-walker. A gait belt was not used to transfer the resident. Interview on 1/5/11 at 7:45 a.m. with CNA E revealed she had forgotten to use the gait belt when transferring resident 2 the day before. 3. Observation on 1/4/11 at 9:40 a.m. revealed two random CNAs transferred a resident from her wheelchair to a recliner in the lounge by lifting her with her shoulders. One of the CNAs placed a gait belt around the resident, then both CNAs placed their arms under the residents arms and lifted the resident. The gait belt was grasped with the opposite hand by the CNA and us… | 2014-04-01 | ||
| 5088 | 5088 | GOLDEN LIVINGCENTER - ARLINGTON | 435050 | 120 CARE CENTER ROAD POST OFFICE BOX 280 | ARLINGTON | SD | 57212 | 2011-01-05 | 282 | D | ZPLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure the care plan was followed for one of nine sampled residents (1). Findings include: 1. Observation on 1/3/11 at 4:40 p.m. revealed: *Resident 1 was heard requesting ice chips, because her mouth was dry. *The certified nurse assistant (CNA) was heard to respond she would check to see if she could have ice chips. *Resident 1 was heard to respond she had previously been able to have ice chips. *The CNA was heard to further respond she could not give her ice chips and that could only be done by the therapist. *The CNA was heard to then offer the resident some water to swish in her mouth but not swallow and some thickened liquid to drink. *The resident was heard to request the water to swish in her mouth. Review of resident 1's physician's orders [REDACTED]. Interview on 1/4/11 at 8:36 a.m. with CNA E revealed: *She always worked on the same wing and knew the residents well. *If there was a new admission or if she had a question she would go to the nurse for direction. *The CNAs did not use the care plans for information regarding the residents. *The CNAs did have an aide bath sheet. During an interview and CNA worksheet review on 1/4/11 at 8:57 a.m. two random CNAs had confirmed with another surveyor the CNAs did not use the care plans to determine the care needed for the residents. They did have a CNA worksheet the nurses completed each day to tell them who to get up, bathe, toilet, weights, oxygen, treatments provided by aides, and who had fell in the last 24 hours. Interview with administrator A on 1/4/11 at 3:50 p.m. revealed she did not know why resident 1 had not received ice chips when requested. As the ice chips were care planned that she could have them. She further wondered who the CNA had asked for directions regarding the ice chips. She asked if it was the dietary manager. Interview with certified dietary manager F on 1/4/11 at 6:30 p.m. revealed she was… | 2014-04-01 | ||
| 5089 | 5089 | GOLDEN LIVINGCENTER - BELLA VISTA | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2011-02-16 | 281 | F | S3VZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure physicians' orders and professional standards were followed for 9 of 13 sampled residents (1, 3, 5, 6, 7, 9, 10, 11, and 13). Findings include: 1. Review of resident 1's physician's re-admission order dated 2/14/11 revealed: -Mupirocin 22 grams (gm) topical ointment had been ordered for "2 days and then stop." The ointment had been ordered to be used on the chin as needed (PRN). That order was not found on the February 2011 medication administration record (MAR) or the treatment administration record (TAR). -[MEDICATION NAME] 325 milligram (mg) tab by mouth had been ordered for a dose of 650 mg every 4 hours PRN for pain or fever. On the February 2011 MAR that order read as Tylenol Arthritis Pain ([MEDICATION NAME]) by mouth for a dose of 650 mg every 6 hours PRN. -A topical skin cleanser (Fleet Bagenema with [MEDICATION NAME] soap) was noted on the February 2011 MAR to be used every three days PRN. That order was not found on the 2/14/11 admission orders [REDACTED]. -Entries on the February 2011 MAR for "[MEDICATION NAME] 10 mg as needed and Fleet Enema 7-19 gm as needed" had no frequency direction noted. Interview on 2/15/11 at 2:45 p.m. and on 2/16/11 at 8:30 a.m. with director of nursing (DON) B and professional services consultant (PSC) C revealed: -The order for Mupirocin had been missed when the admission nurse had entered the medications into the computer system for the MAR. The DON stated the night nurse was responsible for checking new orders for accuracy, but that nurse must have missed the Mupirocin order. A tube of the ointment had been received from the pharmacy but had not been used on the resident. -The order for [MEDICATION NAME] had not been entered correctly. The nurse had chosen the wrong medication from a list of Tylenol choices which then made the frequency incorrect. That error had not been corrected when reviewed by the night nurse. -Th… | 2014-04-01 | ||
| 5090 | 5090 | GOLDEN LIVINGCENTER - BELLA VISTA | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2011-02-16 | 371 | F | S3VZ11 | Based on observation, testing, record review, and interview, the provider failed to maintain the kitchen in a clean and sanitary manner. Findings include: 1. Random observations in the kitchen from 2/14/11 through 2/15/11 revealed: *The trash cans were soiled with splatters ranging in size from a small crumb to quarter size of debris and dried particles. *Wire shelving units that held clean dishes were visibly dirty with a dried on yellow substance that was sticky to touch. *The saran wrap dispenser was visibly dirty and sticky to touch. *The sides and edges of the work table were visibly soiled with a red, sticky, grime build-up. *The can opener was visibly soiled with a back and dark red substance (photo 3). *The pads under the steamer legs contained a build-up of a tan, brown residue (photo 5). *All of the the windows were spattered with an unknown substance. *The red protector caps over the sprinkler heads were coated with a greasy, dusty build-up. *The fire and smoke alarms were dirty with greasy, dusty build-up (photos 8 and 9). *The convection oven was soiled with large amounts brown stains and burned particles inside and out. *The floor was soiled with an unknown liquid substance and food particles scattered throughout the kitchen and dishwasher room (photos 7 and 11). *The floor behind equipment and against the walls was dirty with dust, debris, and food particles ranging in size from a small crumb to a dinner roll (photos 4 and 12). *The exterior dishwasher was soiled with a build-up of sticky grime and food particles (photo10). *The table the mixer sat on was soiled with loose and dried on substances. *The mixer was soiled at the blade insertion area with built-up sticky substances (photo 6). *There was exposed plaster and cracks in the ceiling above clean storage shelves and food preparation and service areas (photos 1 and 2). Interview with director of dietary services D on 2/15/11 at 5:25 p.m. revealed: *There was a daily and monthly cleaning list. *She stated sometimes the scheduled cleaning was no… | 2014-04-01 | ||
| 5091 | 5091 | GOLDEN LIVINGCENTER - BELLA VISTA | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2011-02-16 | 441 | E | S3VZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure proper technique had been followed for four of four observed dressing changes for three of three residents (7, 8, and 9). Findings include: 1. Observation on 2/15/11 from 2:50 p.m. through 3:10 p.m. revealed registered nurse (RN) G performed a dressing change to both resident 9's feet. Director of nursing (DON) consultant M was also present during the observation. RN G washed her hands and then: *Placed a clean towel on the bed. *Removed the pressure relieving boot and sock from resident 9's right foot. *Moved the garbage can closer to the bed. *Used hand sanitizing gel. *Took a pair of gloves from her pocket and put them on. *Removed more gloves from her pocket and placed them on that clean towel. *Placed the dressing change supplies on that clean towel. *Removed a pen from her pocket and wrote the date on a [MEDICATION NAME] border dressing. *Placed the pen back into her pocket. *Removed a dressing from resident 9's right foot. *Sprayed Saf-Cleanse onto clean gauze and cleansed the open area on resident 9's right foot. *Removed a pair of scissors from her pocket. *Without sanitizing the scissors she cut a piece of the [MEDICATION NAME] dressing with those scissors and placed the [MEDICATION NAME] on the clean towel. *Placed the scissors on the clean towel. *Removed her gloves and did not wash her hands or use hand sanitizing gel. *Put on clean gloves she had previously removed from her pocket. *Placed the piece of [MEDICATION NAME] dressing to the open area on resident 9's right foot. *Removed the [MEDICATION NAME] border dressing from the package and touched the surface that would be in contact with the open wound. *Removed her gloves and placed the sock and pressure relieving boot on resident 9's right foot. RN G then: *Removed the pressure relieving boot and sock on resident 9's left foot. *Removed her gloves. *Washed her hands. *Cut a length of gauze with … | 2014-04-01 | ||
| 5092 | 5092 | GOLDEN LIVINGCENTER - BELLA VISTA | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2011-02-16 | 425 | E | S3VZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure orders for medications for 2 of 13 sampled residents (7 and 10) were clarified to prevent actual or potential medication administration errors. Findings include: 1a. Review of resident 10's medication administration records (MAR) for November and December 2010 and January and February 2011 revealed: *Trazadone (anti-depressant) was ordered by mouth, 50 milligrams (mg), one-half to one tablet at bedtime every day. *The medication had been initialed by staff as given every day at bedtime. *No entries had been made by staff if a one-half or one of a tablet had been given to the resident. Review of the resident's consultant pharmacist reviews from 4/7/10 through 2/3/11 revealed there were no entries that addressed the lack of documentation for the dosage of Trazadone given to resident 10. Review of the provider's medication administration guidelines revised in June 2005 revealed all current medications and dosage schedules were listed on the resident's MAR and administered according to facility policy. No policy was provided that directed unlicensed assistive personnel (UAP) how to determine the dosage to be given when it was not clear. b. Review of resident 10's MAR for November and December 2010 and January and February 2011 revealed: *Trazadone was ordered by mouth, 50 milligrams (mg), one-half to one tablet at bedtime every day. *UAP F initialed she had given the medication on 2/1/11 at 9:00 p.m. *No entry was made as to how much was given to the resident on that date. Interview on 2/16/11 at 9:10 a.m. with UAP I confirmed if Trazadone had a range of one-half to one tablet on the MAR she would assess the resident for lethargy before determining how much to give the resident. If she was still unsure she would then contact the nurse for input. Interview on 2/16/11 at 10:40 a.m. with UAP F confirmed: *She did not remember how much of the Trazadone she had given on 2/1/11 to resi… | 2014-04-01 | ||
| 5093 | 5093 | GOLDEN LIVINGCENTER - BELLA VISTA | 435060 | 302 ST CLOUD STREET | RAPID CITY | SD | 57701 | 2011-02-16 | 253 | E | S3VZ11 | Based on random observation, testing, and interview, the provider failed to maintain the following areas and/or items: - The toilet traps and/or the caulking around the bases of toilets in seven resident rooms 107, 108, 111, 212, 301, and 310. - The linoleum was heaved and/or cracked in four resident bathrooms 210, 212, 301, and 310. - The door frame to resident room 207. - The west bathing room tile floor in the shower area. - The bathroom door in resident room 204. Findings include: 1. Random observation on 2/14/11 from 3:00 p.m. to 6:15 p.m. and on 2/15/11 from 8:20 a.m. to 11:00 a.m. revealed the toilet traps had chipped and scratched porcelain in resident rooms 107, 108, 212, 301, and 310. Those chips ranged in size from golf balls to baseballs (photos 16, 17, and 18). The scratches were embedded in the porcelain and looked like a layers of pencil lead laid in the bottom of the toilet (photo 26). Interview with maintenance supervisor (MS) J and district maintenance supervisor (DMS) K at the time of the observations confirmed those findings. They stated they were not aware those toilet traps were chipped and scratched. Additional observation during the above dates and times revealed the caulk around the base of the toilets in resident rooms 111 and 310 was laid in layers that resembled ribbon frosting on a cake (photos 19 and 24). Those layers of caulk were bumpy to the touch and had several crevices and grooves that could fill with dirt and debris. Interview with MS J at the time of the observations confirmed those findings. He stated he had not laid that caulk but agreed it needed to be redone to be easily cleanable. 2. Random observation on 2/14/11 from 3:00 p.m. to 6:15 p.m. and on 2/15/11 from 8:20 a.m. to 11:00 a.m. revealed the linoleum was heaved, bulged, separated from the wall, and/or cracked in resident bathrooms 210, 212, 301, and 310 (photos 14, 20, 21, and 25). That heaved and bulged linoleum created an uneven walking surface that would not recede to the sublfloor when stepped on by this surveyo… | 2014-04-01 | ||
| 5094 | 5094 | TIESZEN MEMORIAL HOME | 435069 | 312 EAST STATE ST | MARION | SD | 57043 | 2011-01-31 | 281 | D | XBEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record reviews, nursing procedure review, and interview, the provider failed to follow established procedures and professional standards for documenting the death of one of one sampled resident (2). Findings include: 1. Review of the nurses notes for resident 2 revealed on [DATE] at 12:20 p.m.: "Called by CNA (certified nurse assistant) to resident room. Resident pale in color with no respirations and no heart rate per auscultation. No blood pressure. Pronounced deceased at 12:20 p.m. ____ son notified of father's death. ____ stated he will call ____ at the funeral home for body to be picked up. Dr. ____ at Avera McGreevy Clinic notified of resident ' s death. Review of the provider ' s [DATE] nursing procedure for death revealed: 1. Notify family. 2. Call Doctor. 3. Document when resp, heart beat, BP (blood pressure) ceased. 4. Call funeral home. 5. Have mortician sign for body. 6. Add to communication board. 7. Add to pharmacy sheet. 8. THIS WAS LINED THROUGH 9. Call DON (director of nurses) (any hour, leave note in administration box. 10. Chart all you did and what time the body left the building. 11. Call chaplain or minister if family wishes. 12. Pull Meds/MAR (medication administration record)/Care Off to the side NOCS (night shift) wait til a.m. Interview on [DATE] at 1:30 p.m. with DON revealed: "We don't pronounce dead. We never chart that way. It's probably the nurse that didn't know." Pursuant to SDCL [DATE].1 Determination of death - Any individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the [DIAGNOSES REDACTED], is dead. A determination of death shall be made in accordance with accepted medical standards. SDCL [DATE] and [DATE].1 - intent is to designate the signing of the Death certificate as a medical act by a physician, physician's assistant, or nurse practitioner. SDCL ,[DATE]A-22(11) Physicia… | 2014-04-01 | ||
| 5095 | 5095 | TIESZEN MEMORIAL HOME | 435069 | 312 EAST STATE ST | MARION | SD | 57043 | 2011-01-31 | 309 | G | XBEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record review, nursing procedure review, professional standards, and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical and psychosocial well being for one of one sampled resident (1) who had no recorded bowel movement (BM) for 13 days. Findings include: ?Review of resident 1's Medicare Assessment Form dated 12/15/10 through 1/19/11 revealed: ?Symbol key for use with documentation that included: -Check mark=assessment matched standard parameter. -H=deviation, chart findings (on this form or focus notes). -Arrow to left=deviation continues, no change since preceding H assessment. -P=pre-existing condition, describe. ?Standard parameters identified for "Gastrointestinal" that pertained to bowel elimination were: -Abdomen soft. -Nontender and nondistended. -Continent of bowels. -Passing [MEDICATION NAME]. -Bowel sounds present times 4 quadrants. -No N (nausea)/V (vomiting), diarrhea, constipation. -No tarry or bloody stools. -Stools brown, semi-soft, formed, describe if abnormal. -Supp (suppository)/enemas: type/color returned. ?12/15/10 at 9:15 p.m. There was a check mark and a note BS (bowel sounds positive X 4. There was also an asterisk with a note that read "res (resident) states BM was "last week." ?12/16/10 at 10:00 a.m. There was a check mark and an asterisk with a note that read "C/o (complains of) constipation Dr. ____ to see res. today will get order for bowels." ?12/16/10 at 8:20 p.m. There was a check mark and an asterisk with a note that read no BM. Those forms dated 12/17/10 at 9:25 a.m. through 1/19/11 at 1:30 p.m. had check marks indicating the assessment matched the standard parameters. There were no other notes on these dates related to bowel elimination. Review of resident 1's BM report roster dated 1/10/11 through 1/24/11 revealed no record of the resident having had a BM after 1/10/11 at 9:27 p.m. until 1/24/11 at 4:0… | 2014-04-01 | ||
| 5096 | 5096 | TIESZEN MEMORIAL HOME | 435069 | 312 EAST STATE ST | MARION | SD | 57043 | 2011-01-31 | 314 | G | XBEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, nursing procedures review, professional standards and interview the provider failed to prevent the development of an additional pressure ulcer and failed to provide accurate documentation of the discovery and course of care for one of one resident (1) with an acquired pressure ulcer. Findings include: Review of resident 1's skin assessment form completed by a nurse on 12/15/10 revealed a stage I (persistent area of skin redness without a break in the skin) pressure ulcer to the coccyx and scattered bruising on both forearms. Review of resident 1's Norton Plus Pressure Ulcer form completed by a nurse on 12/22/10 revealed a score of 6. A score of 6 out of 20 indicated a higher level of risk for pressure ulcer development. The Norton Scale is a total rating scale that measures functional capabilities and other health care issues of the person that contribute to his/her risk in developing pressure ulcers. Review of resident 1's nurse notes from 12/15/10 through 1/24/11 pertaining to the skin revealed: ?12/15/10 Admit - Treatments for "discolored area on buttocks" and left (L) abd. (abdominal) fold. ?12/28/10 at 5:15 p.m. Norton pressure scale done quarterly. Stage I area to coccyx area reddened, no open areas, no dressing, no swelling noted. ?12/31/10 at 11:00 a.m. R (right) buttock scabbed area no redness or drainage noted; 1 cm diameter. ?1/4/10 (incorrect year) at 2:20 p.m. Norton pressure scale done quarterly, score 6. Currently has a stage I to coccyx being treated with [MEDICATION NAME] BID (twice daily) until healed. Has pressure relieving mattress, repositioned per turn sheet, supplements given. ?1/5/11 at 2:30 a.m. Resident has 4 cm diameter blister to heel of L foot. Dark-red in color and fluid filled. No drainage presently. ?1/6/11 at 11:50 a.m. .... (2) Protective boot/device L foot heel wound (3) clean daily-reapply dressing. ?1/6/11 at 1:45 p.m. Has unstageable (not able to determine severity) pressure area t… | 2014-04-01 | ||
| 5097 | 5097 | BETHESDA HOME OF ABERDEEN | 435073 | 1224 S HIGH ST | ABERDEEN | SD | 57401 | 2011-05-04 | 253 | E | RHFO11 | Based on random observation and interview, the provider failed to maintain the following areas and/or items: *Schedule the cleaning and maintenance for two of three whirlpool tub rooms E wing and A wing to prevent potential cross-contamination. *Schedule the maintenance of tables in the dining room: -Six of eight plastic tables. -Four of twenty-four wooden tables. -Wooden doors in the main dining room and various ones throughout the facility. *Registers in resident rooms and hallways on eight of eight wings. *Wooden hand rails in eight of eight wings. *One cracked padded toilet seat in resident room (406). *One broken flush handle on a toilet in a resident room (404). *Loose cupboard doors in the G wing kitchenette and the activity room. *A gallon of drinking water located under the sink along side a small black plunger in the G wing kitchenette. *A sling lift on G wing. Findings include: 1. Random observation of the E wing tub room on 5/2/11 from 3:00 p.m. to 4:30 p.m. revealed: *Areas on the tub lift where paint had chipped away exposing rust and an uncleanable surface (photo 1). *An area where a protective piece of plastic on the tub lift had broken off exposing a sharp uncleanable surface (photo 1). *Deep scratches inside the tub near the back and bottom had removed the surface coating making it unable to be cleaned (photo 2). *A large amount of white and dark brown debris covered the outer edges of the trim around the tub (photo 3). *Four of four casters on a shower chair had rusted and created a non cleanable surface (photo 5). Random observation of the A wing tub room on 5/2/11 revealed: *A round hole on the inside of the tub created a noncleanable surface (photo 4). *A large amount of dark brown and green debris on the outside trim of the tub (photo 7). Interview with certified nurses assistant (CNA) J on 5/3/11 at 8:15 a.m. revealed housekeeping was responsible for cleaning the outside of the tubs. Interview on 5/4/11 at 9:40 a.m. with the housekeeping/laundry supervisor revealed: *The bath aides were re… | 2014-04-01 | ||
| 5098 | 5098 | BETHESDA HOME OF ABERDEEN | 435073 | 1224 S HIGH ST | ABERDEEN | SD | 57401 | 2011-05-04 | 441 | E | RHFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, testing, and interview, the provider failed to ensure: *An effective process was used to identify and clean contaminated surfaces in resident rooms. *The chemicals and process used to sanitize all of the laundry was effective against drug resistant organisms. *Medical equipment was cleaned and stored properly after use. *Food and drink were not stored in resident care areas. Findings include: 1 a. Observation at 8:55 a.m. on 5/4/11 revealed a housekeeper and cart in the D wing. Interview with the housekeeper at the time of the observation revealed she used a quaternary disinfectant in the mop bucket. Testing of the solution in the mop bucket at that time revealed the proper amount of disinfectant was in the mop bucket. b. Observation at 2:55 p.m. on 5/4/11 revealed the housekeeping supervisor had filled a mop bucket with the quaternary disinfectant into a mop bucket from the G wing housekeeping closet. Testing of the solution revealed 100 parts per million (ppm). c. Observation at 3:10 p.m. on 5/4/11 revealed the housekeeping supervisor had filled a mop bucket with the quaternary disinfectant into a mop bucket from the D wing housekeeping closet. Testing of the solution revealed 200 ppm. Interview on 5/4/11at 9:40 a.m. with the laundry supervisor at 9:40 a.m. revealed: *She was unaware of the strength of the chemicals that had been dispensed into the mop buckets. *She did not have the tools available to test the ppm strength of the chemical used for the mop buckets. *She agreed there was an inconsistency with the amount of chemicals that had been dispensed from the auto dispensers in the house keeping closets. 2. Interview 5/4/11 at 9:40 a.m. with the laundry supervisor revealed: *There had been previous cases of Clostridium Difficile in the facility. *She was unaware of the strength of the chemicals that had been dispensed into the laundry machines that were used for all of the laundry. *She was unaware what chem… | 2014-04-01 | ||
| 5099 | 5099 | BETHESDA HOME OF ABERDEEN | 435073 | 1224 S HIGH ST | ABERDEEN | SD | 57401 | 2011-05-04 | 334 | D | RHFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the provider failed to offer seasonal flu immunizations to three of three sampled residents (1, 18, and 19). Findings include: 1. Review of the Bethesda immunization permission form revealed residents 1, 18, and 19 refused the influenza immunization at admission and had not been offered the yearly flu immunization since their admission. At the time of admission new residents are required to sign the Bethesda immunization permission form designating either consent to or refuse of annual flu immunizations. This form states "Bethesda Home will utilize this one-time consent to immunize yearly for influenza ... " Review of the resident influenza immunization record for 2010-2011 revealed an " R " had been placed along side the name of resident 1, 18, and 19 who had refused flu immunizations at admission. Lines were drawn through the documentation row indicating the resident had not been offered the immunization. The provider had mailed influenza immunization information letters dated October 5, 2010 to all resident families, including the families of resident 1, 18, and 19. The letter stated "This is for your information only, no response is required as we have the permission and physician orders [REDACTED]. Interview with nurse B on 5/3/11 at 10:30 a.m. revealed the admission influenza consent or refusal was followed. Interview with nurse B also revealed residents had not been asked each year if they wanted the influenza vaccine. Interview with nurse C on 5/4/11 at 9:32 a.m. confirmed the same. | 2014-04-01 | ||
| 5100 | 5100 | BETHESDA HOME OF ABERDEEN | 435073 | 1224 S HIGH ST | ABERDEEN | SD | 57401 | 2011-05-04 | 241 | E | RHFO11 | Based on random observation, interview, and policy review, the provider failed to ensure dignity was considered for five randomly observed residents during feeding assistance at four meals in the dining room. Findings include: 1. Observation on 5/3/11 during the supper meal in the dining room revealed a certified nursing assistant (CNA) L: -Used a spoon to assist a resident to eat her supper. -Used the edge of the spoon to scrape spilled food from the resident's lips and chin. -Used a spoon to pick up a quarter sized area of pureed food from the resident's bib and had placed it back onto the resident's plate. 2. Observation on 5/4/11 during the breakfast meal in the dining room revealed dietary aide H: -Used a spoon to assist a resident to eat her breakfast. -Used the edge of the spoon to scrape spilled food from the resident's lips and chin. 3. Random observation during the noon meal on 5/4/11 revealed a CNA assisting the resident. The spoonful of food the CNA had attempted to feed the resident was too large a portion. The excess food remained on the resident's face until the CNA used the spoon to clean off the resident's mouth. The excess food that had been cleaned off the mouth area was put back into the dish to be served again. 4. Random observation on 5/4/11 at 7:45 a.m. in the dining room revealed dietary staff R while feeding two different residents at the same time: *Wiped the mouth area of two residents with a paper napkin and went from one resident to the other without sanitizing her hands between residents. *Picked food off one of the resident's clothing protector and put it back into the serving bowl to be served again. *Used the spoon to scrape excess food off the resident's mouth and put that same spoon back into the serving bowl. 5. Review of the provider's 8/30/10 policy for dignity and dining revealed: *"Do not use utensils to clean off resident's mouth/face i.e. like feeding a child-use napkin (not clothing protector) even if you must use several napkins during the meal." *Ensure proper infectio… | 2014-04-01 | ||
| 5101 | 5101 | BETHESDA HOME OF ABERDEEN | 435073 | 1224 S HIGH ST | ABERDEEN | SD | 57401 | 2011-05-04 | 371 | E | RHFO11 | Based on observation, interview, and policy review, the provider failed to store, prepare, distribute and serve food under sanitary conditions for two observed meals as follows: *Meal preparation and serving from the tray line in the kitchen. *Distribution of meals in the dining area. *Feeding residents using proper hand cleaning techniques. Findings include: 1. Observation on 5/3/11 at 11:30 a.m. of the tray line for the noon meal revealed: *Dietary staff N touched her nose, pushed her glasses up on her nose, touched her hair, and did not sanitize hands before she filled more meal trays. *She left the tray line to go to the cupboard and stove, and put on pot holder mitts. *She returned to the tray line without cleaning her hands. *She went to the stove to get a new pan of lasagna, returned to the tray line, and used the spatula to lift up the used pan from the steam table. She then used that same soiled spatula to continue putting lasagna onto the residents' serving plates. *Her hands were not cleaned after the pot holder mitts were removed. *She removed a piece of garlic bread from one plate and put it back into the large stock of bread. *She again touched her glasses, nose, and other parts of her personal clothing, did not sanitize her hands, and continued to fill the residnets' plates. *She continued the same processes throughout the entire time she prepared the noon meal plates. 2. Observation at the same time revealed dietary staff O: *Touched the inside of the soup bowls with her thumb when filling them. *Coughed into her hand and elbow area when holding a plate of food. *Left the tray line to get a paper towel to wipe spilled soup off her hand, used the same paper towel to wipe spilled soup off the side of a soup bowl, and placed it on the serving tray. *At no time during the above process did she use hand sanitizer or wash her hands. 3. Observation at the same time revealed dietary staff P: *Touched the telephone, handed it to another staff person, and then returned to putting food on the noon trays with… | 2014-04-01 | ||
| 5102 | 5102 | THE NEIGHBORHOODS AT BROOKVIEW | 435083 | 2421 YORKSHIRE DR | BROOKINGS | SD | 57006 | 2011-01-05 | 323 | E | UQHU11 | Based on observation and interview, the provider failed to ensure: *Resident walkers were appropriately utilized for randomly observed residents (17 and three unidentified). *A door leading to a hazardous area was secured and had an appropriate locking device. Findings Include: 1. Random observations on 1/3/11 and 1/4/11 of the east and south hallways revealed: *Three unidentified residents were observed on 1/3/11 during the supper hour being pushed backwards down the east hallway in their wheeled walkers to the dining room. The residents were seated in the center of the walker facing backwards. Staff members were pushing them using the handles of the walkers. *Resident 17 on 1/4/11 at 2:00 p.m. was being pushed backwards down the south hallway in the resident's wheeled walker. The resident was seated in the center of the walker facing backwards and a staff member was pushing the resident using the handles of the walker. The resident was transported from the south hallway nurses station to the dining room where she attended an activity. Interview on 1/4/11 at 2:10 p.m. with case manager (CM) E revealed: *Several residents down the east hallway were transported within the facility via their wheeled walkers in the above described manner. *Residents were transported in that manner after they became too tired to walk with the aid of the walker. Interview on 1/4/11 at 2:15 p.m. with CM B revealed she had one resident in the south hallway who was transported in the above described manner, and that was resident 17. Interview on 1/4/11 at 2:20 p.m. with physical therapist G revealed: *Residents should not be transported via wheeled walkers with the center seat. *She was not aware facility staff were utilizing the walkers in that fashion. *She agreed residents should never be transported backwards as it might make the resident disoriented and dizzy. *Use of the wheeled walkers with a center seat as a means of resident transport was against the manufacturer's suggested use. Interview on 1/4/11 at 2:45 p.m. with CM B reveal… | 2014-04-01 | ||
| 5103 | 5103 | THE NEIGHBORHOODS AT BROOKVIEW | 435083 | 2421 YORKSHIRE DR | BROOKINGS | SD | 57006 | 2011-01-05 | 441 | D | UQHU11 | Based on observation, interview, and policy review, the provider failed to ensure appropriate glove use and hand hygiene for two of two observed residents (9 and 10) receiving personal care. Findings include: 1. Observation on 1/4/11 at 11:20 a.m. of personal care given resident 10 by certified nurse aide (CNA) D revealed: *On several occasions the CNA was seen touching, the resident and multiple surfaces in the resident's room with her gloved hands that had been exposed to body fluids. *The CNA did not wash her hands immediately after the removal of her gloves that had been exposed to body fluids. *The CNA used her bare hands to push into a garbage can personal care items that had been exposed to body fluids. Her hands were not washed until several minutes after exposure. Prior to washing her hands she again touched the resident and multiple surfaces in the resident's room. 2. Observation on 1/4/11 at 1:00 p.m. of the personal care given resident 9 by CNA D revealed: *On several occasions the CNA was seen touching the resident and multiple surfaces in the resident's room with her gloved hands that had been exposed to body fluids. *The CNA did not wash her hands immediately after removal of gloves that had been exposed to body fluids. *The CNA tied a garbage bag closed with her gloved hands that had been exposed to body fluids. That same garbage bag was later transported bare handed from the resident's room to the dirty utility room. After leaving the dirty utility room the CNA went to another resident's room to assist with the care of another resident without performing any hand hygiene. 3. Interview and policy review on 1/5/11 at 10:30 p.m. with case manager B revealed: *She agreed proper glove use and hand hygiene was not properly adhered to based on this surveyor's observations. *According to the provider's policy on handwashing dated 7/22/04: -Handwashing was the most important means of preventing nosocomial infection. -Hands must be washed before and after resident contact, after contact with body fluids, a… | 2014-04-01 | ||
| 5104 | 5104 | THE NEIGHBORHOODS AT BROOKVIEW | 435083 | 2421 YORKSHIRE DR | BROOKINGS | SD | 57006 | 2011-01-05 | 164 | B | UQHU11 | Based on observation, interview, and record review, the provider failed to ensure resident identifiable information contained on the electronic medication record was not visible to the residents or public by two of four nurses (E and F) observed administering medications. Findings include: 1. Random observations on 1/3/11 between 3:45 p.m. and 5:05 p.m. revealed licensed practical nurse (LPN) F was administering medications on the north hallway. The LPN would go to different residents' rooms to administer medications. While she was away from the medication cart resident identifiable information included on the electronic medication record screen was visible to passing residents or members of the public. 2. Observation of the medication pass on 1/3/11 from 5:45 p.m. to 5:55 p.m. revealed registered nurse (RN) E was administering medications on the east hallway. On two occasions the RN went into residents' rooms to administer medications. While she was away from the medication cart resident identifiable information included on the electronic medication record screen was visible to passing residents or members of the public. 3. Random observations on 1/4/11 between 5:45 p.m. and 6:00 p.m. revealed LPN F was administering medications with the medication cart located in the main lobby. The LPN would go into the dining room to administer medication to residents. While she was away from the medication cart resident identifiable information included on the electronic medication record screen was visible to passing residents or members of the public. 4. Review of the provider's policy for confidentiality, security, and integrity within information systems effective 8/1/97 revealed: *The policy had been developed to maintain confidentiality, security, and integrity of data/information contained within computer systems. *All data information maintained on any computer system was governed by the confidential information section of the provider's personnel policies manual. *The confidentiality portion of the policy did not in… | 2014-04-01 | ||
| 5105 | 5105 | RIVERVIEW MANOR | 435086 | 611 EAST 2ND AVE | FLANDREAU | SD | 57028 | 2011-01-05 | 279 | E | UUM911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the provider failed to develop comprehensive collaborative care plans for three of three sampled residents (4, 10, and 11) receiving hospice services. Findings include: 1a. Review of resident 4's Minimum Data Set ((MDS) dated [DATE] revealed: *It was an admission assessment. *He/she was on hospice. Review of resident 4's care plan dated 12/30/10 revealed: *He/she was terminally ill. *Hospice services were identified as an approach. *The care plan did not address: -How often hospice services were provided. -What services were to be provided by hospice. -How the provider and the hospice were going to coordinate and divide up the provision of services and care for the resident. Review of resident 4's entire medical record revealed: *There were two separate binders that included documents regarding resident 4's care. -One of those binders included the provider care. -The second binder contained documentation made by the hospice provider. Interview on 1/4/10 at 11:15 a.m. with licensed practical nurse E revealed she was unaware the second binder for resident 4 contained only hospice documentation. Review of the hospice's contract with the provider dated 7/20/04 revealed "The hospice and the home will develop a mutually acceptable overall plan of care for the resident." b. Review of resident 11's nurses notes from 12/16/10 through 1/4/11 revealed the resident had repeated bouts of [MEDICAL CONDITION], redness, and shiny, taut skin on his/her right shin. At times he/she complained of pain in his/her shin. It was documented hospice was notified several times about that. There was no reference to the physician being notified. Review of resident 11's care plan dated 12/7/10 revealed: *The resident had a potential for pain related to arthritis and a neck fracture. *Hospice services were provided for debilitation. *A problem related to maintaining his/her weight with a hospice care approach. *There we… | 2014-04-01 | ||
| 5106 | 5106 | GOOD SAMARITAN SOCIETY CORSICA | 435089 | 455 NORTH DAKOTA | CORSICA | SD | 57328 | 2011-01-25 | 225 | D | 3RX511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to properly investigate and report one of one alleged instance of certified nursing assistant misconduct with one of one sampled resident (1). Findings include: 1. Review of the investigative report submitted to the South Dakota Department of Health by the provider on 1/10/11 revealed: *Inappropriate conduct with resident 1 was alleged to have occurred on 12/23/10. *Investigation into the alleged misconduct did not occur until 12/29/10. *No documentation was found in the report indicating the alleged misconduct had been reported to any State of South Dakota agency prior to that time. Review of resident 1's entire medical record revealed: *No documentation was present related to the 12/23/10 incident. *Resident 1's cognitive status was documented as impaired. Interview on 1/25/11 at 9:25 a.m. with resident 1 revealed she was cognitively unable to answer questions regarding the 12/23/10 incident. Interview on 1/25/11 at 9:35 a.m. with certified nursing assistant (CNA) 4 revealed: *She believed she had seen CNA 5 kiss resident 1 on the lips on 12/23/10 at around 1:00 a.m. CNA 5's back was turned to her at the time she stated she had witnessed that occurrence. *She had reported what she had thought she had seen to registered nurse (RN) 3 shortly after the incident had occurred that night. *No incident report was filed, and she had not formally documented the incident in the resident's record. *She had not had any personal or professional problems with CNA 5 prior to that incident. *She continued to work with CNA 5 throughout the rest of that night. *She had worked with CNA 5 multiple other times since the incident she had reported on 12/23/10. She had not witnessed any inappropriate behavior with residents after the above incident. Interview on 1/25/11 at 10:45 a.m. with office manager 6 revealed: *She had sat in on the interview of CNA 5 with director of nursing (DON) 2 on… | 2014-04-01 | ||
| 5107 | 5107 | LAKE ANDES HEALTH CARE CENTER | 435097 | 740 EAST LAKE ST POST OFFICE BOX 130 | LAKE ANDES | SD | 57356 | 2011-01-05 | 494 | E | 9E3F11 | Based on record review and interview, the provider failed to ensure: *Three of four nurse aides (E, F, and G) working in the facility became certified before four months had elapsed from their dates of hire. *The provider maintained their nurse aide program requirements as specified by the State of South Dakota. Findings include: 1. Review of nurse aide E's certified nursing assistant pathway form revealed 8/24/10 was the date the nurse aide had begun the initial 40 hours textbook and skills training. Four months from that date was 12/24/10. Review of nurse aide E's certified nurse aide competency evaluation results dated 12/22/10 revealed a score of 57% on the knowledge portion of the test. A score of 75% or more was required to pass the test to become certified as a nursing assistant. The schedule for December 2010 and January 2011 revealed nurse aide E worked a seven hour shift on 1/1/11 after failing the nurse aide certification testing and had been employed more than four months. 2. Review of nurse aide F's certified nursing assistant pathway form revealed 8/24/10 was the date the nurse aide had begun the initial 40 hours textbook and skills training. Four months from that date was 12/24/10. Review of nurse aide F's certified nurse aide competency evaluation results dated 12/22/10 revealed a score of 59% on the knowledge portion of the test. A score of 75% or more was required to pass the test to become certified as a nursing assistant. The schedule for December 2010 and January 2011 revealed nurse aide F continued to work the following shifts after failing the nurse aide certification testing and had been employed more than four months: *A 12 hour shift on 12/24/10. *A 12 hour shift on 12/27/10. *A 12 hour shift on 12/30/10. *A 12 hour shift on 1/1/11. *A 12 hour shift on 1/2/11. 3. Review of nurse aide G's certified nursing assistant pathway form revealed 8/24/10 was the date the nurse aide had begun the initial 40 hours textbook and skills training. Four months from that date was 12/24/10. Review of nurse… | 2014-04-01 | ||
| 5108 | 5108 | LAKE ANDES HEALTH CARE CENTER | 435097 | 740 EAST LAKE ST POST OFFICE BOX 130 | LAKE ANDES | SD | 57356 | 2011-01-05 | 202 | D | 9E3F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure proper documentation was done for one of one closed resident records (10) who was transferred to another facility. Findings include: 1. Review of resident 10's record revealed: -Resident 10 had an admission date of [DATE]. -A progress note dated [DATE] written by the physician noted "A lot of behavior problems." -A [DATE] nursing note stated the resident was out of the facility and had been transported with administrator A and dietary manager K to a behavior facility in Sioux Falls. -No documentation was noted in the nursing notes describing resident 10's status after [DATE]. -No physician's order to transfer or transport the resident had been received from the physician. -No documentation was noted from the physician regarding the reason for the transfer. -No recap of stay/discharge summary of the resident's stay was noted in the record. Interview on [DATE] at 9:50 a.m. and at 11:30 a.m. with director of nursing B revealed: -There were no other notes or documentation found from the physician regarding the transfer. -The nursing notes had not contained any further information of the resident's status after [DATE]. -The recap of stay/discharge summary was not done. -She had known the resident was now deceased but had not known the date of death . | 2014-04-01 | ||
| 5109 | 5109 | LAKE ANDES HEALTH CARE CENTER | 435097 | 740 EAST LAKE ST POST OFFICE BOX 130 | LAKE ANDES | SD | 57356 | 2011-01-05 | 283 | D | 9E3F11 | Based on record review and interview, the provider failed to ensure a discharge summary was done for one of one closed resident record (10). Findings include: 1. Review of resident 10's record revealed no discharge summary or recap of stay had been completed. Refer to F202 finding 1. | 2014-04-01 | ||
| 5110 | 5110 | LAKE ANDES HEALTH CARE CENTER | 435097 | 740 EAST LAKE ST POST OFFICE BOX 130 | LAKE ANDES | SD | 57356 | 2011-01-05 | 499 | D | 9E3F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review and interview, the provider failed to ensure one of one certified nurse aide (CNA) (H) had a current nurse aide certification. Findings include: 1. Review of CNA H's employee file revealed a copy of her nurse aide certification. That certification had an expiration date of [DATE]. Interview on [DATE] at 3:30 p.m. with office manager I and administrator A revealed CNA H was currently on maternity leave and had last worked at the facility as a CNA on [DATE]. Interview on [DATE] at 3:40 p.m. with director of nursing (DON) B and registered nurse consultant C confirmed CNA H's certification had expired on [DATE]. DON B further stated she had notified CNA H about the expiration date of her certification. CNA H had planned to come to the facility that day to complete the necessary paperwork for renewal of her certification. | 2014-04-01 | ||
| 5111 | 5111 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2011-03-09 | 441 | E | FOR111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure one of one resident's (1) clean dressing change was completed in a sanitary and [MEDICATION NAME] manner. Findings include: 1. Observation on 3/8/11 from 8:30 a.m. until 8:38 a.m. of registered nurse (RN) D applying a clean dressing on resident 1's right sacral wound after a bath revealed RN D with ungloved hands: *Opened two different dressing packages and laid them on the resident's bed. *Left the room to get a pair of scissors. *Returned to the room with a pair of blue-handled, all-purpose scissors. *Without washing her hands or using an alcohol-based hand rub used those scissors to cut the hydrogel dressing to size and applied it directly to the wound. *Applied the second dressing over the hydrogel dressing and the wound. *Washed her hands. *Left the room and returned those blue-handled scissors to the pencil box at the nurse's station. Further observation revealed that pencil box contained another pair of all-purpose scissors and numerous pens and pencils. Interview at that time with RN D revealed: *She had washed her hands after first entering resident 1's room. *She had not washed her hands or used an alcohol-based hand rub after returning to the resident's room with the scissors, because she had not "touched anything." Interview with the director of nursing at 8:40 a.m. confirmed RN D had used those blue-handled scissors from the pencil box to cut resident 1's hydrogel dressing, and had returned them to that box on the desk. She further revealed she had ordered bandage scissors for each resident but had not received them yet. Interview with RN D on 3/8/11 at 1:50 p.m. confirmed she had not cleaned those scissors prior to using them to cut resident 1's hydrogel dressing. She had cleaned them before putting them back in the pencil box. Review of the provider's handwashing/hand hygiene policy revised March 16, 2010 revealed staff should have used an alcohol… | 2014-04-01 | ||
| 5112 | 5112 | BOWDLE NURSING HOME | 435107 | 8001 W 5TH STREET POST OFFICE BOX 556 | BOWDLE | SD | 57428 | 2011-03-09 | 281 | E | FOR111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure 2 of 3 nurses (E and F) followed professional standards when providing medications to residents (1&11) during 2 of 41 opportunities observed during medication passes. Findings include: 1. Observation on 3-8-11 at 4:15 p.m. during a medication pass revealed nurse F crushed and administered potassium chloride 20 meq (milliequivalent) CR (controlled release) to resident 11. Review of the medication container label stated the medication was potassium chloride 20 meq CR. A DO NOT CRUSH label was on that medication cassette. Review of resident 11's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Todd P. Semla et al., Geriatric Dosage Handbook, 15th Ed., Lexi-Comp, Hudson, Ohio, 2010, pages 1411 and 2024, revealed controlled release potassium tablets were not to be crushed or altered. Review of resident 11's Current Meds order form signed and dated by the physician extender on 2-16-11 revealed there was no order to crush medications. Interview on 3-9-11 at 1:45 p.m. with facility employee C revealed extended release medications were not to be crushed. 2. Observations on 3-7-11 at 5:05 p.m. of nurse E and on 3-8-11 at 10:55 a.m. of nurse F revealed resident 1 was administered two sprays in each nostril of Nasal Spray 0.65% (Normal Saline). Review of resident 1's March 2011 MAR indicated [REDACTED]. May have at bedside. Review of the Current Meds order form revealed: Normal Saline Nasal Spray 1 spray each nostril qid (four times a day) prn, do use it Bid (twice a day). Review of the pharmacy label on the bottle of Nasal Spray revealed 2 sprays were to be administered in each nostril. Interview on 3-9-11 in the morning with nurse G confirmed the order should have been clarified with the physician as to whether one or two sprays was the correct dose. | 2014-04-01 | ||
| 5113 | 5113 | ST WILLIAMS HOME FOR THE AGED | 435122 | 100 SOUTH 9TH STREET | MILBANK | SD | 57252 | 2011-01-12 | 164 | E | FYSY11 | Based on observation, interview, and policy review, the provider failed to ensure resident medical information was kept confidential for eight random observations of two of two medication carts. Findings include: 1. Random observations from 5:00 p.m. on 1/10/11 through 6:10 p.m. on 1/11/10 revealed: *Eight times the medication administration records (MAR) were left open on the top of the medication carts. *That revealed resident medical information to anyone passing by. *The medication carts were stationed in various areas of the hallways, and especially the hallway between the front door and the nursing station. *That hallway was busy with residents, visitors, and staff going back and forth. Interview on 1/12/11 at 10:40 a.m. with nurse A revealed: *Leaving the MARs open was a breach of confidentiality. *All staff were required to read and sign a copy of the confidentiality policy. Review of the provider's confidentiality policy dated January 2005 revealed "Information known or contained in the resident's medical record will be treated as confidential." | 2014-04-01 | ||
| 5114 | 5114 | ST WILLIAMS HOME FOR THE AGED | 435122 | 100 SOUTH 9TH STREET | MILBANK | SD | 57252 | 2011-01-12 | 176 | D | FYSY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to determine if self-administration of medications was safe for three of four sampled residents (3, 10, and 13). Findings include: 1. Observation and interview on 1/11/11 at 4:30 p.m. with resident 13 revealed he/she kept Aspercreme, [MEDICATION NAME], and artifical tears in his/her room. Review of the resident's physician's orders [REDACTED]. Review of resident 13's medical record revealed there was not an assessment completed by an interdisciplinary team to determine if keeping and using those medications in his/her room was a safe practice. 2. Observation on 1/11/11 at 8:05 a.m. revealed nurse Q: *Set up the oral medications in applesauce and drew up insulin for resident 10. *Assisted the resident into a private area. *Handed him/her the cup with the medications and applesauce in it. *Gave the insulin to the resident. *Helped the resident to the dining room door and returned to the medication cart. *The resident propelled his/her wheelchair up to a table and took his/her medications by himself/herself without supervision by nurse Q. Interview on 1/12/11 at 10:40 a.m. with nurse A revealed: *A self-administration assessment needed to be done at the time the order was written. *The nurse who signed off on the physician's orders [REDACTED]. Interview with resident 10 on 1/12/11 at 10:05 a.m. revealed sometimes the nurses did not watch her take her medications. She usually took her medication right away when the nurse handed them to her. But she was eating something that morning when the nurse brought her medicine. She did not believe any of her tablemates would try to take her medications by mistake. She would tell the nurse if they did. Interview and chart review with nurse Q on 1/12/11 at 10:50 a.m. revealed: *There was no orders for resident 10 to allow self-administration of medications or to allow the resident to have medications left with her to take … | 2014-04-01 | ||
| 5115 | 5115 | ST WILLIAMS HOME FOR THE AGED | 435122 | 100 SOUTH 9TH STREET | MILBANK | SD | 57252 | 2011-01-12 | 371 | E | FYSY11 | Based on observation, interview, and policy review, the provider failed to ensure four of four observed meals were distributed and served under sanitary conditions in the dining areas. Findings include: 1. Observation at 5:45 p.m. on 1/10/11 during the evening meal in the dining room revealed: *Certified nurse assistant (CNA) J held the cover to the pink insulated individual serving tray against the front portion of her uniform and alongside her leg area while waiting in the serving line. *Dietary aide (DA) F delivered meals to residents using a red plastic tray, placed the tray on the table near many different residents, and reused that same tray many times during the meal distribution. *DA F and housekeeping staff (HS) H both touched the prewrapped silverware packets and placed them on the soiled red trays. The trays were soiled with wet liquid and food particles from the previous delivered meal. *HS H wiped his/her hand across the face area then continued to touch silverware packets, held the red tray next to the side of his/her legs when returned from the resident to the tray line. No handwashing was ever completed throughout the entire meal distribution. *Cold order cook G removed the plastic lids to beverage glasses throughout the entire meal distribution and touched the top area of the glasses. His/her gloved hands however had touched the coffee machine, carts, and steam table all with the same pair of gloves on. *G also removed individual ice cream portions from the wrappers and wore the same gloves as mentioned above. *Cook I touched the refrigerator doors, ice cream boxes, steam table, and serving plates without any handwashing. 2. Observation during the noon meal in the dining room at 11:35 a.m. on 1/11/11 revealed: *DA K wiped his face and nose area numerous times during the meal distribution, continued to deliver food on the red tray to residents, touched silverware packets, drinking glasses, and plates without washing his hands. *M took covers off the beverage glasses, touched the tops of the glasse… | 2014-04-01 | ||
| 5116 | 5116 | ST WILLIAMS HOME FOR THE AGED | 435122 | 100 SOUTH 9TH STREET | MILBANK | SD | 57252 | 2011-01-12 | 441 | D | FYSY11 | Based on observation, interview, and policy review, the provider failed to ensure soiled linens were transported in a manner to prevent the possible spread of infection for one or four random observations. Findings include: 1. Observation on 1/10/11 at 6:25 p.m. revealed certified nurse assistant (CNA) J: *Helped resident 2 change clothes and get into bed. *After she had helped him/her get comfortable she picked up his/her dirty clothes and towels. *Bundled them against her uniform and carried them in the hall to the soiled linen hamper. Interview on 1/12/10 at 10:30 a.m. with infection control nurse E revealed the staff were taught to put soiled laundry into a plastic bag to carry it in the halls. Review of American Health Care Association, How to be a Nurse Assistant, 4th Ed., Salem, MA., 2008, pp. 142, revealed "Always carry linen by holding it away from your uniform, even if it is not visibly soiled." 2. Observation on 1/11/11 at 7:30 a.m. revealed a randomly observed CNA carried unbagged soiled linens from a resident's room across the hall to the soiled linen room. 3. Observation on 1/11/11 at 9:45 a.m. revealed CNA U removed a soiled incontinent pad from a resident's bed and carried it from the resident's room down the hallway to the soiled linen room without bagging the soiled linen. Interview with staff Z on 1/12/11 at 8:35 a.m. revealed CNA U was not a new CNA and had worked there for a few years. 4. Observation on 1/12/11 at 8:15 a.m. revealed CNA U carried a huge amount of soiled bed linens from a resident's room down the hallway to the soiled linen room without bagging the soiled linen. Interview with staff person Z on 1/12/11 at 8:35 a.m. revealed CNA U was not a new CNA and had worked there for a few years. 5. Interview with staff person X on 1/12/11 at 7:50 a.m. revealed the staff were to bag soiled linen and clothing before removing it from resident rooms. Soiled linen bags were provided for the staff to use on each wing. 6. Review of the provider's resident laundry policy dated 10/19/04 revealed … | 2014-04-01 | ||
| 5117 | 5117 | ST WILLIAMS HOME FOR THE AGED | 435122 | 100 SOUTH 9TH STREET | MILBANK | SD | 57252 | 2011-01-12 | 425 | D | FYSY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure the appropriate disposition of medications for one of two closed records (14) reviewed. Findings include: 1. Review of resident 14's closed record revealed there was no documentation for the disposition of the following medications: [REDACTED] *Senna with DSS. *Darifenacen. *Donepezel. *Terazosin Hcl (hydrochloride). *Esomeprazole. *Aspirin EC (enteric coated). Interview with nurse E on 1/12/11 at 11:20 a.m. revealed: *She and director of nursing A had searched for additional information without success. *The Senna and the aspirin were from stock bottles and could not be checked as to what was done with the pills left. *The darifenacen, donepezel, Terazosin Hcl, and the esomeprazole were on punch cards and should have been returned to the pharmacy. There was no documentation available as to what was done with those medications. | 2014-04-01 | ||
| 5118 | 5118 | ST WILLIAMS HOME FOR THE AGED | 435122 | 100 SOUTH 9TH STREET | MILBANK | SD | 57252 | 2011-01-12 | 281 | D | FYSY11 | Based on observation, interview, and policy review, the provider failed to ensure one of three licensed nurses (P) administered medications according to professional standards. Findings include: 1. Observation on 1/10/11 at 5:55 p.m. revealed nurse P: *Set medications into three different medication cups. *Stacked the cups with the medications in them. *Carried the cups into the dining room. *Gave one cup to a resident by the windows. *Crossed the dining room and gave another cup to a second resident. *Went to the north end of the dining room and gave a third resident the last cup. *She watched in the dining room a few minutes, then returned to the medication cart she was using. Interview on 1/12/11 at 10:40 a.m. with nurse A revealed the nurses were not to set-up more than one resident's med at a time. Review of the provider's administration of medication policy dated 3/1/06 revealed "Only one resident's medication is to be prepared at a time." | 2014-04-01 | ||
| 5119 | 5119 | STRAND-KJORSVIG COMMUNITY REST HOME | 435125 | 801 S MAIN POST OFFICE BOX 195 | ROSLYN | SD | 57261 | 2010-12-15 | 281 | D | 77SW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure: *Appropriate dressing change procedures and standards were followed by nursing staff for one of two observed dressing changes (3). *Appropriate procedures and infection control practices were followed during personal care for one of three sampled residents (11). Findings include: 1. Observation on 12/14/10 at 9:45 a.m. revealed resident 3 had a dressing change to her left outer ankle. Licensed practical nurse (LPN) F washed her hands prior to starting the procedure. She continued with the procedure as follows: *Laid all the dressing supplies on the resident's bed on top of the bedspread. *Applied gloves and removed the soiled dressing. *With the same gloves on she cleaned the left outer ankle wound. *With the same gloves on she applied a new dressing to the left outer ankle wound. *Removed the gloves, disposed of the supplies, and washed her hands. Interview on 12/15/10 at 10:30 a.m. with director of nursing D and infection control nurse E revealed: *The policy/procedure for a nonsterile dressing change was not followed correctly. *The dressing supplies should have been placed on a paper towel and not directly on the resident's bedspread. *New gloves and handwashing should have been completed before cleansing the wound. *New gloves and handwashing should have been completed before applying the new dressing. Review of the undated nonsterile dressing policy/procedure revealed: *"Prepare a clean dry work area at bedside by placing a paper towel/chux on top of the treatment cart and assembling necessary supplies." *"Don clean gloves, remove soiled dressing, and discard in bag. Remove gloves and place in bag." *"Wash hands thoroughly." *"Don another pair of gloves of clean gloves and cleanse wound with normal saline. Discard materials and gloves in bag." *"Wash hands thoroughly, don another pair of clean gloves, and apply clean dressings as prescribed." 2. Observati… | 2014-04-01 | ||
| 5120 | 5120 | STRAND-KJORSVIG COMMUNITY REST HOME | 435125 | 801 S MAIN POST OFFICE BOX 195 | ROSLYN | SD | 57261 | 2010-12-15 | 368 | C | 77SW11 | Based on interview and policy review, the provider failed to offer each resident a substantial snack at bedtime. Findings include: 1. Interview during the group meeting with eight residents on 12/14/10 at 10:15 p.m. revealed: *The staff did not offer them a snack at bedtime. *They knew they could get something to eat after supper, but they had to ask for it. Interview on 12/15/10 at 10:50 a.m. with the director of nursing D revealed: *The certified nurse aides were to pass bedtime snacks to the residents. *She did not know the residents had to ask for them. *She could not find a policy for the passing of bedtime snacks in the nursing policy manual. *She stated she would ask dietary if they had one. Review of the dietary department's policy for meal service, snacks, and substitutions revised 10/15/10 revealed: *"The dietary department will ensure that between meals and/or bedtime snacks are available for the request of the residents." *"Bedtime snacks will be provided by the dietary department." *"A cart will be assembled by dietary and delivered to the nursing department before leaving in the evening." *"The cart will be taken to the resident's rooms by nursing." | 2014-04-01 | ||
| 5121 | 5121 | STRAND-KJORSVIG COMMUNITY REST HOME | 435125 | 801 S MAIN POST OFFICE BOX 195 | ROSLYN | SD | 57261 | 2010-12-15 | 441 | D | 77SW11 | Based on observation, interview, and policy review, the provider failed to ensure: *One of two sampled residents (3) dressing changes were performed in a clean and sanitary manner. *One of three observations of handwashing and glove usage with resident's personal care (11) was performed in a clean and sanitary manner. *Laundry staff handled processing and transporting of soiled linen in a safe and sanitary manner. Findings include: 1. Observation and interviews on 12/14/10 and on 12/15/10 regarding the dressing changes for resident 3 revealed infection control standards were not followed. Refer to F281, finding 1. 2. Observation and interviews on 12/15/10 at 9:22 a.m. during resident 11's personal care revealed infection control standards were not followed. Refer to 281, finding 2 3. Observation and interviews on 12/15/10 at 9:22 a.m. during resident 11's personal care revealed infection control standards were not followed. Refer to 281, finding 3. 4. Observation on the afternoon of 12/14/10 revealed the laundry staff person J was transporting soiled linen in the hallway while wearing a protective gown and gloves. Observation on 12/15/10 at 9:00 a.m. revealed laundry supervisor I was transporting the soiled linen cart in the hallway to the laundry while wearing a protective gown and gloves. Interview with laundry supervisor I on 12/15/10 at 9:40 a.m. revealed the laundry staff had two gowns to wear when transporting soiled linen carts in the hallways and sorting soiled linens. The gowns were not dedicated, so only one gown was worn for sorting soiled laundry and the other was to be used only when transporting soiled linen carts in the hallways. At times during the day the gowns could have been used to sort laundry contaminating the gowns, before wearing them through the hallways to transport the soiled linen carts. Interview with the interim administrator A on 12/15/10 at 9:50 a.m. revealed: *She was not aware the soiled linen carts could be transported through the hallways without wearing protective clothing and… | 2014-04-01 | ||
| 5122 | 5122 | STRAND-KJORSVIG COMMUNITY REST HOME | 435125 | 801 S MAIN POST OFFICE BOX 195 | ROSLYN | SD | 57261 | 2010-12-15 | 161 | C | 77SW11 | Based on record review and interview, the provider failed to ensure the surety bond protected resident personal funds for loss other than that occurred by employee dishonesty for all residents of the facility. Findings include: 1. Review of the information on the surety bond indicated residents' funds were protected from "employee or employees when the dishonest act of the employees shall have been committed." The bond did not protect the residents' funds from losses occurring as a result of acts or errors of negligence, incompetence, or dishonesty. The bond did not specify that the obligee may collect due to any failure by the facility, whether by commission, bankruptcy, or omission, to hold, safeguard, manage, and account for the residents' funds as required. Interview with administrator B on 12/14/10 at 1:00 p.m. revealed he was not sure if the bond offered protection of residents' funds from anything more than employee dishonesty. Interview with administrator B and administrator-in-training C on 12/14/10 at 2:47 p.m. revealed the requirements of the surety bond were being faxed to the insurance company for review. Interview with administrator-in-training C on 12/15/10 at 12:30 p.m. revealed the insurance company had forwarded the information regarding the additional coverage the bond needed to provide to the surety bond company for review and adjustment to the bond to meet the requirements. | 2014-04-01 | ||
| 5123 | 5123 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 334 | D | BBUQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to document for 2 of 14 sampled residents (8 and 11) if a pneumococcal or influenza vaccination had been: *Received prior to entering the facility. *Offered and declined while the resident was in the facility. *Administered within the facility after admission. Findings include: 1. Review of resident 11's medical record for pneumococcal and influenza vaccinations revealed: *She was admitted on [DATE]. *The form used to record immunization status was documented to indicate there was no record of the resident receiving a pneumococcal vaccination. The resident's last influenza vaccination was documented as 10/2/08. *A consent form dated 12/7/10 related to immunizations was signed by resident 11 but not completed. The permission section to administer the pneumococcal vaccination one time and the influenza vaccination annually were not documented either "Yes" or "No." The area to document the date of a previous pneumococcal vaccination was not completed. *A FAX communication to resident 11's physician signed by the physician on 12/8/10 indicated there was no record of a pneumococcal vaccination and the last influenza vaccination was 10/2/08. *There was no documentation in the rest of resident 11's health care record of her ever receiving a pneumococcal vaccination or an influenza vaccination after 10/2/08. The provider was given the opportunity to find documentation to support resident 11 having received a pneumococcal vaccination at any time or an influenza vaccination after 10/2/08. The provider could not supply any documentation for the above. Interview on 6/15/11 at 9:25 a.m. with resident 11 revealed: *She was not aware of having received a pneumococcal or influenza vaccination from the provider. *Her physician would have known if she had received them before. *She would have consented to receiving the pneumococcal and influenza vaccinations from the provider. 2. Review of resident 8's … | 2014-04-01 | ||
| 5124 | 5124 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 279 | D | BBUQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to ensure care plans were comprehensive and individualized for 2 of 16 sampled residents (2 and 3). Findings include: 1. Review of resident 3's entire medical record revealed: *Documentation in the nurse's note on 5/20/11 stated a Foley catheter (tube to drain urine) had been inserted. *The signed and dated 6/8/11, June 2011 physician orders [REDACTED]. *An order dated 5/20/11 to record the urinary output from the Foley catheter. *A care plan that had a problem, goal, and approach for urinary incontinence. -The typed next review date of the care plan was 5/12/11. -The hand written next review date of the care plan was 8/25/11. *That same care plan did not contain a focus care planned area for the catheter. Interview on 6/15/11 at 10:30 a.m. with the director of nurses (DON) revealed: *She agreed a focus problem area for the Foley catheter should have been added to the care plan. *She was unsure if there was a policy for care plans. 2. Review of resident 2's medical record revealed the provider failed to develop a comprehensive care plan that addressed his room change and transition to the new room location. Refer to F247. | 2014-04-01 | ||
| 5125 | 5125 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 281 | D | BBUQ11 | Based on record review and interview the provider failed to ensure physician's orders were obtained before implementing a nursing procedure for 1 of 16 sampled residents (3). Findings include: 1. Review of resident 3's entire medical record revealed: *An untimed notation on 5/6/11 by a registered nurse (RN) in the progress notes. That notation stated a residual catheterization had been done and returned 300 cubic centimeters (cc) of urine. -There was no physician's order for that catheterization. *At 4:30 p.m. on 5/19/11 a notation in the progress notes by an RN stated the resident had been catheterized, and 575 ccs of urine was obtained. *There was no physician's order for that catheterization. Interview on 6/14/11 at 1:45 p.m. with RN C revealed: *She stated there was no order in resident 3's chart for those catheterizations. *She stated there was no comminication in the resident's chart to the physician regarding those catheterizations. Interview on 6/15/11 at 10:30 a.m. with the director of nurses revealed: *She stated there were no orders for the catheterizations on 5/6/11 and 5/19/11. *She agreed there should have been a physician's order obtained prior to those catheterizations. *She was unable to locate a policy for physician's orders. | 2014-04-01 | ||
| 5126 | 5126 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 371 | D | BBUQ11 | Based on observation and interview, the provider failed to ensure proper sanitary procedures were followed while serving the meal for two of two observed meal services. The staff failed to: *Store ready-to-serve food containers in a manner that avoided cross-contamination. *Change gloves and wash hands to prevent cross-contamination. Findings include: 1. Observation on 6/14/11 from 11:25 a.m. through 12:30 p.m. revealed cook D: *Had stored small covered food pans inside large covered food pans on the steam stable. -The large pans contained french fries and chicken nuggets that touched the outside of the small pans. -The smaller pans contained ground and pureed ready-to-serve food. *Removed the small pans from the large pans and sat them on the front serving counter and served the food from them. *Put those same small pans back into the larger pans. *Those smaller pans touched the food in the large pans and cross-contaminated the food. 2. Observation on 6/14/11 at 5:25 p.m. revealed the certified dietary manager (CDM) while serving the evening meal and wearing gloves: *Left the serving area. *Opened the refrigerator door and removed cheese. *Opened the cupboard and removed bread. *Opened the bread bag and took out bread slices. *Made a sandwich. *Closed the bread bag. *Returned to the serving area and without removing her gloves or sanitizing her hands continued serving the evening meal. Interview on 6/15/11 at 9:10 a.m. with the CDM revealed: *She agreed the storage of the small pans inside the larger pans that contained food was cross-contamination. *She agreed she should have washed her hands and/or changed her gloves before returning to the serving line to have avoided cross-contamination. | 2014-04-01 | ||
| 5127 | 5127 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 441 | D | BBUQ11 | Based on observation, interview, and policy/procedure review, the provider failed to ensure proper infection control practices were followed for: *Handwashing and glove use during one of one observed resident's (4) treatments and care by a nurse. *Use of gloves during three of three observed resident's (4, 15, and 16) care provided by a certified nursing assistant. Findings include: 1. Observation on 6/14/11 at 3:10 p.m. of nurse A while she provided care to resident 4 revealed she entered the resident's room and without washing her hands or putting on gloves: *Removed the soiled dressing from the feeding tube ostomy site and threw it away. *Placed a clean dressing on the site. *Assembled the nebulizer inhalation chamber and placed the nebulizer solution in the chamber. *Placed the nebulizer mask with the chamber attached to the resident's face for inhalation and started that treatment. *Then accessed the port to the feeding tube with a syringe and drew back on the plunger of the syringe to check for residual fluids in the stomach. *Then using a stethoscope listened as she injected air into the feeding tube to check for proper placement of the tube. *Used the syringe to flush the tube with water. *Then gave a bolus feeding by way of the feeding tube and flushed with water again. *Clamped off the feeding tube and closed the port access. *Then removed the nebulizer mask and chamber from the resident's face. *Took the feeding tube syringe and the nebulizer equipment to the resident's bathroom room sink and rinsed them with water. *Placed them on a clean towel to dry. *Left the resident's room. *Knocked on other resident doors and opened the doors with her hands to check for staff until they were located. *Used hand sanitizer after she had located the staff and had returned to the medication cart. Review of the 2006 clean dressing change policy revealed: *Gloves should have been worn during the dressing change. *The gloves should have been changed after the soiled dressing was removed and before the clean dressing wa… | 2014-04-01 | ||
| 5128 | 5128 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 278 | D | BBUQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure assessment information for 2 of 14 sampled residents (8 and 11) was accurate for: *Immunizations. *Diagnosis. Findings include: 1. Review of resident 11's Minimum Data Set (MDS) 3.0 assessments revealed: *12/14/10, 3/8/11, and 5/31/11 - The section for influenza vaccine received in the facility was documented as "No." The documentation for the reason why the influenza vaccine was not received stated "Offered and declined." *12/21/10 - The section for influenza vaccine received in the facility was documented as "Yes." The date of administration was documented as "11/22/10." *12/14/10, 12/21/10, 3/8/11, and 5/31/11 - The section for pneumococcal vaccination was documented as being up to date. *12/14/10, 3/8/11, and 5/31/11 - The [DIAGNOSES REDACTED]." *12/21/10 - The [DIAGNOSES REDACTED]." Review of resident 11's medical record revealed there was no documentation the resident: *Had received an influenza vaccination while in the facility or from another provider after 10/2/08. *Had been offered by the provider the opportunity to receive or decline an influenza vaccination. *Had ever received a pneumococcal vaccination. *Had ever had [MEDICAL CONDITION]. Interview on 6/15/11 at 4:25 p.m. with registered nurse A and the social worker designee revealed they were not aware of resident 11 having [MEDICAL CONDITION]. Refer to F334, finding 1. 2. Review of resident 8's 12/14/10, 3/8/11, and 5/31/1 MDS 3.0 assessments revealed the section for pneumococcal vaccination was documented as being up to date. Review of resident 8's medical record revealed there was no documentation the resident had received a pneumonia vaccination while in the facility or from another provider. Refer to F334, finding 2. | 2014-04-01 | ||
| 5129 | 5129 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 247 | D | BBUQ11 | Based on record review, policy review, and interview, the provider failed to furnish advance notice to 1 of 14 sampled residents (2) before moving him to another room. Findings include: 1. Review of resident 2's nursing progress notes from 12/26/10 through 4/18/11 revealed: *He had been in one room on 1/15/11. *On 2/6/11 he was in a different room. *He continued to be in the new room at the time of the survey. *No entries were made in the nursing progress notes that explained the room change. Review of the social services progress notes from 10/25/10 through 3/17/11 revealed no explanation for the room change. Review of resident 2's Minimum Data Set assessments for 12/7/10 and 2/22/11 revealed no behaviors had been exhibited by the resident during that time frame. Review of the care plan in place from 12/10/10 through 3/2/11 revealed no explanation or approaches that addressed the room change for resident 2. Review of the provider's undated resident's rights pamphlet provided in the admission packet to residents revealed: *A subheading "Accomodation of Needs". *Under that subheading it stated the resident would receive notice before a room or roommate would be changed. *A subheading "Social Services". *Under that subheading it stated the provider would "provide social services to attain or maintain your highest level of well-being". Interview on 6/15/11 at 9:10 a.m. with the interim director of nursing confirmed: *The room change occurred before she was employed by the provider. *The room change occurred before the present social services designee was employed by the provider. *She would have expected documentation that addressed the room change for resident 2. *She would have expected documentation by the social services department that addressed the room change. *It should have been an interdisciplinary team decision. *The care plan should have addressed the room change. *The care plan should have included approaches to help with adjustment for the resident after the room change . Interview on 6/15/11 at 11:15 … | 2014-04-01 | ||
| 5130 | 5130 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 250 | D | BBUQ11 | Based on record review, policy review, and interview, the provider failed to maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 14 sampled residents reviewed (2). Findings include: 1. The provider's social service's designee failed to provide an assessment or interventions when resident 2 was moved. Refer to F247. | 2014-04-01 | ||
| 5131 | 5131 | VIOLET TSCHETTER MEMORIAL HOME | 435126 | 50 SEVENTH ST SE POST OFFICE BOX 946 | HURON | SD | 57350 | 2011-06-15 | 431 | D | BBUQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider did not ensure controlled substance medications were accounted for and destroyed for one of two residents (14) sampled for closed record review. Findings include: 1. Review of the closed record for resident 14 revealed she died on [DATE]. The medication administration records (MAR) revealed: *Fentanyl patch 12 microgram (mcg) was started on [DATE]. Three patches were documented as administered. *Acetaminophen 500 milligram (mg)/hydrocodone 5 mg was started on [DATE]. Eight tablets were documented as administered. *Fentanyl patch 25 mcg was started on [DATE]. Two patches were documented as administered. *Morphine sulfate solution 20 mg/1 milliliter (ml) was started on [DATE]. Nineteen 0.5 ml doses were documented as administered for a total of 9.5 ml. Interview on [DATE] at 2:09 p.m. with consultant pharmacist J revealed: *The pharmacy had delivered controlled substance medications for resident 14 to the provider: - Five fentanyl 12 mcg patches on [DATE]. - Thirty tablets of acetaminophen 500 mg/hydrocodone 5 mg on [DATE]. - Five fentanyl 25 mcg patches on [DATE]. - One bottle (30 ml) of morphine sulfate solution 20 mg/1 ml on [DATE]. That bottle was sent to replace a 30 ml bottle that was removed by the provider from the emergency supply. *The consultant pharmacist who served the facility had been to the facility on [DATE]. It was not known if the consultant pharmacist and a nurse had destroyed any controlled substances at that time. If controlled substances had been destroyed, the only copy of the destruction record was maintained by the provider. Surveyor calculation revealed the quantities of controlled substances should have been remaining following the death of resident 14: *Two fentanyl 12 mcg patches. *Twenty-two tablets of acetaminophen 500 mg/hydrocodone 5 mg. *Three fentanyl 25 mcg patches. *Partial 30 ml bottle of morphine sulfate solution 20 mg/1 ml containing 20.5 ml. Interview o… | 2014-04-01 | ||
| 5132 | 5132 | DOW RUMMEL VILLAGE | 435127 | 1321 W DOW RUMMEL ST | SIOUX FALLS | SD | 57104 | 2011-01-20 | 221 | D | 8H2U11 | Surveyor Preceptor Based on observation, interview, record review, and policy review, the provider failed to do ongoing assessment and care planning for restraint use for one of two sampled residents (9) with restraints. Findings include: 1. Review of resident 9's entire medical record on 1/19/11 at 4:00 p.m. revealed: *The physician's original order dated 10/20/09 stated the resident may use Geriatric (geri) chair with lap tray (restraint). *Care plan approaches dated 10/20/10 revealed: -"Restraint protocol will be followed as long as she uses the geri-chair." -"Lap tray will be removed during meals." Random observation on 1/19/11 from 11:45 a.m. to 12:30 p.m. of resident 9 revealed: *At 11:45 a.m. she was placed at the dining room table in a geri-chair with a lap tray. *At 12 noon she was still sitting at the table in the geri-chair with the lap tray on drinking a glass of water. *At 12:05 p.m. she was banging a glass with ice on the side of the geri-chair lap tray. *At 12:15 p.m. she was sitting at the table in the geri-chair with the lap tray and had not received her meal. The other four residents at the table had received their food. *At 12:30 p.m. a staff member placed a meal on the table in front of resident 9 who continued to sit in the geri-chair with lap tray. Interview on 1/19/11 at 4:30 p.m. with director of nursing (DON) A and director of assisted living H revealed: -Both agreed an initial assessment had not been done for resident 9's restraint. -Restraints were reviewed monthly at the quality of life meetings. Review of the provider's policy for Physical Restraints dated 8/1/97 revealed: *Nursing staff and the care team would complete the Physical Restraint Elimination Assessment quarterly at care plan conferences. *The resident's care plan would be updated to include the reason for the restraint, the required monitoring, and a measurable goal related to the rationale for its use. Interview with DON A on 1/20/11 at 8:15 a.m. revealed: *She agreed the provider's policy for physical restraints had not… | 2014-04-01 | ||
| 5133 | 5133 | DOW RUMMEL VILLAGE | 435127 | 1321 W DOW RUMMEL ST | SIOUX FALLS | SD | 57104 | 2011-01-20 | 281 | D | 8H2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and interview, the provider failed to ensure professional standards were upheld as evidenced by: *One of twelve sampled residents (5) failed to receive medications as ordered by her physician at admission, and one of one resident (7) with a physician order [REDACTED]. *One of twelve sampled residents (18) medication administration records (MAR) had discrepancies from one month to the next month that were not clarified. *One of two sampled residents (14) who were administered insulin was given an expired medication. *Three of four observed residents (14, 16, and 17) insulin administrations were done without using universal precautions. Findings include: 1. Interview with resident 5 on [DATE] at 4:30 p.m. revealed she: *Had been a resident for only a couple of weeks. *She had lived in an assisted living facility prior to going to the hospital for pneumonia. *Had arthritis and had always had a lot of pain because of that. *Was kind of upset, because she had just found out she was not receiving any medication for pain. *Knew she was having some more pain recently but thought it was because she was getting therapy. *Received her medications from the nurses in a small cup. *Knew she was getting more medications now then she had before so did not realize she was not getting anything for pain. Review of resident 5's [DATE] MAR indicated [REDACTED]. Review of resident 5's physician's orders [REDACTED]. *an order for [REDACTED]. *Further review revealed a discharge treatment form dated [DATE] from the hospital with an order for [REDACTED]. Interview with registered nurse (RN) C revealed the above orders were the admission orders [REDACTED]. They should have went by the discharge treatment form dated [DATE] for the specific physician's orders [REDACTED]. Review of resident 5's nurses notes dated [DATE] revealed "One (1) page of MARs from assisted living (AL) not faxed to pharmacy when transferred to Al… | 2014-04-01 | ||
| 5134 | 5134 | DOW RUMMEL VILLAGE | 435127 | 1321 W DOW RUMMEL ST | SIOUX FALLS | SD | 57104 | 2011-01-20 | 282 | D | 8H2U11 | Surveyor Preceptor Based on observation, interview, and record review, the provider failed to ensure care plans were followed for the use of a restraint for one of two sampled residents (9). Findings include: 1. Review of resident 9's care plan dated 10/20/10 revealed: *"Restraint protocol will be followed as long as she uses the geri chair." *"Lap tray will be removed during meals." Refer to F221, finding 1. | 2014-04-01 | ||
| 5135 | 5135 | DOW RUMMEL VILLAGE | 435127 | 1321 W DOW RUMMEL ST | SIOUX FALLS | SD | 57104 | 2011-01-20 | 431 | E | 8H2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor Preceptor Based on observation, interview, and policy review, the provider failed to maintain safe and secure storage of medications in one of one medication room and one of two medication carts. Findings include: 1. Random observation on 1/18/11 from 4:45 p.m. through 6:10 p.m. revealed: *The medication room door was open at 4:45 p.m. -Licensed nurse (LN) C was sitting at the nurses desk with her back to the medication room. -Multiple prescriptions were on the counter in the medication room. -At 4:50 p.m. LN C went into the open medication room, then returned to the nurses desk positioning herself with her back to the open medication room door. -At 4:53 p.m. certified nursing assistant (CNA) D went into the medication room through the open door, obtained a walkie talkie, and left through the open medication door. -At 4:55 p.m. LN C got up from the nurses station and closed the medication room door. *At 5:15 p.m. LN E unlocked the medication room door, opened the door, and then sat down at the nurses station. *At 5:18 p.m. LN C and LN E were sitting at the nurses station with their backs to the open medication room door. *At 5:20 p.m. LN C went in and out of the open medication room, then returned to the nurses desk positioning herself with her back to the open medication room door. *At 6:10 p.m. LN E was sitting at the nurses station with her back to the open medication room door. 2. Random observation on 1/18/11 from 5:15 p.m. through 6:00 p.m. revealed: *At 5:15 p.m. LN C left the medication cart unlocked and went and sat down by the nurses station. -Resident 15 with a [DIAGNOSES REDACTED]. *At 5:30 p.m. LN C walked away from the unlocked medication cart. *At 5:40 p.m. LN C left the medication cart unlocked and unattended as she went into the medication room. *At 5:47 p.m. in the dining room LN C was administering medications to the residents. -Residents were entering and exiting the dining room. -On multiple observations LN C wal… | 2014-04-01 | ||
| 5136 | 5136 | DOW RUMMEL VILLAGE | 435127 | 1321 W DOW RUMMEL ST | SIOUX FALLS | SD | 57104 | 2011-01-20 | 441 | D | 8H2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, the provider failed to implement an infection control procedure that notified housekeeping of the type of infectious organism in isolation rooms. Findings include: 1. Interview with director of housekeeping and laundry J on 1/20/11 at 8:00 a.m. revealed: *Housekeeping staff were not notified of the type of infectious organism in isolation rooms. *She was aware certain organisms such as Clostridium difficile (C. diff) would require specific disinfectants to be controlled. *She was aware the current disinfectant the facility used would not be effective against [DIAGNOSES REDACTED]. *If [DIAGNOSES REDACTED] was in the facility the housekeeping staff would continue to use the current disinfectant until they were notified. Interview with infection control registered nurse (RN) B on 1/20/11 at 10:00 a.m. revealed: *She would expect the charge nurse to notify housekeeping of the infectious organism before they cleaned the room. *She was not aware housekeeping was not notified of the infectious organism. *She agreed housekeeping should be notified of the infectious organism, so they could use the proper cleaning procedures. Interview with RN C, a charge nurse, on 1/20/11 at 10:12 a.m. revealed: *She would not inform the housekeeping staff of the type of infectious organism in the isolation room. *She would inform the housekeeping staff of the proper contact precautions they should follow when cleaning the room. | 2014-04-01 | ||
| 5137 | 5137 | GOOD SAMARITAN SOCIETY SELBY | 435123 | 4861 LINCOLN AVENUE | SELBY | SD | 57472 | 2010-12-22 | 281 | E | Y8ZR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure appropriate infection control and medication administration procedures were followed by two of two nurses (C and D) during 16 of 32 random observations of medication administration in the dining room. Findings include: 1. Observation on 12/20/10 from 5:15 p.m. until 6:05 p.m. during medication administration revealed nurse C: *Poured pills into the palm of her hand from two separate pill bottles and then put the pills into the medication cup. *Punched a pill from the prepackaged punch card into the medication cup. Using her fingers she removed the pill, broke it in half, and returned the two halves of the pill to the medication cup. *Placed a medication cup on the top of the medication cart and poured a liquid medication in the cup. She then proceeded to raise the medication cup to eye level. The medication cup contained an excessive amount of medication. She then proceeded to pour the excess medication back into the bottle. *Poured pills into the palm of her bare hand from two separate pill bottles and then placed the pills in the medication cup. *Poured pills from a pill bottle into the palm of her hand, used her fingers to remove pills from the mouth of another pill bottle, and again poured pills from another pill bottle into the palm of her hand and placed all the pills in the medication cup. *Poured medication into a resident's orange juice and left the juice with the resident at the table to consume. *Left medications at the table with numerous residents during the evening meal. Returned to the medication cart to document the medications as taken without observing those residents taking their medications. Further observation during that time revealed nurse C opened the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She looked at the MAR, and then proceeded to retrieve the medications from the cart and set-up the medic… | 2014-03-01 | ||
| 5138 | 5138 | AURORA-BRULE NURSING HOME | 43A107 | 408 SOUTH JOHNSTON STREET | WHITE LAKE | SD | 57383 | 2010-12-01 | 441 | E | QEWS11 | Based on observation, interview, and record review, the provider failed to ensure medical equipment was cleaned after use for five of five blood-sugar testings for. Findings include: 1. Observation on 11/29/10 between 5:00 p.m. and 5:50 p.m. revealed licensed nurse C: *Took the treatment cart into resident 6's room. *Took a glucometer out of a plastic box on the treatment cart. *Prepared the glucometer to test the resident's blood-sugar test. *Placed the glucometer on the resident's furniture and proceeded to do the blood-sugar. *Completed the blood-sugar test, removed the test strip, and replaced the glucometer into the plastic box on the treatment cart without cleaning it. *Went directly to resident 14's room, followed the same procedure, and again replaced the glucometer into the plastic box without cleaning it.. *Went directly to resident 15's room, followed the same procedure, and again replaced the glucometer into the plastic box without cleaning it. 2. Observation and interview on 11/30/10 between 11:45 a.m. and 11:50 a.m. revealed licensed nurse B: *Took the treatment cart into the director of nurses' (DON) office. *Resident 6 entered the office and sat in a chair. *Nurse B took the glucometer out of the plastic box on the treatment cart. *Prepared the glucometer and tested the resident's blood-sugar. *Replaced the glucometer back into the plastic box on the treatment cart. *After resident 6 left the DON's office, the nurse had resident 15 come in and sit in the chair. *Nurse B followed the same procedure and replaced the glucometer back into the plastic box. When asked if she ever cleaned the glucometer after use the nurse left the DON's office without replying and returned with a container of the appropriate type of wipes. She placed the container of wipes on the treatment cart and cleaned the glucometer. 3. Interview on 12/1/10 at 8:45 a.m. with the DON revealed: *The glucometer was to be cleaned after each resident. *The wipes used to clean the glucometer were supposed to be kept on the treatment cart… | 2014-03-01 | ||
| 5139 | 5139 | AURORA-BRULE NURSING HOME | 43A107 | 408 SOUTH JOHNSTON STREET | WHITE LAKE | SD | 57383 | 2010-12-01 | 281 | D | QEWS11 | Based on record review, interview, and policy review, the provider failed to follow physician's orders for one of one sampled resident (6) that went on a therapeutic leave. Findings include: 1. Review of resident 6's physician's orders dated 10/29/10 revealed the following orders: *Oxygen 5 liters per nasal cannula through C-Pap (Continous Positive Airway Pressure) at night. Resident may self-administer. *Oxygen per nasal cannula to keep oxygen saturation at 90 percent or greater. *Therapeutic passes with medications. Review of resident 6's nurses notes revealed: *"11/25/10 - 1100 out of facility (OOF) with family -stable. *11/26/10 - 1800 Returned (Rtn) to facility without incident." *The nurses notes were signed by nurse A. Interview on 11/29/10 at 5:00p with resident 6 revealed when she had gone on therapeutic leaveon 11/25/10 they had not sent her oxygen with her. She had done okay, but it was a little hard without the oxygen. She was not sure why she did not have the oxygen, but thought it was because she only had a big oxygen concentrator. They had sent the C-pap machine. Review of the provider's 3/1/10 Therapeutic home passes with medications (meds)/treatment policy revealed: *"A nebulizer, oxygen concentrator, and or C-pap machines need arrangements made, possibly home health, unless they own their own machines. *Meds are to be counted and charted in nurses notes, when resident leaves and upon their return, include the treatment (rx) number (#) in the charting." Interview with nurse A on 12/1/10 at 7:45 a.m. revealed she really could not say for sure if resident 6 had oxygen with her when she left on therapeutic leave. Someone else was getting her ready while nurse got her medications set up to go. Interview on 1/29/10 at 5:00 p.m. with the director of nurses E revealed: *The nurses should have documented all the medications that had been sent with resident 6. They had not followed their policy. *Resident 6 should have had the oxygen sent along with her medications when she left the facility. | 2014-03-01 | ||
| 5140 | 5140 | UNITED RETIREMENT CENTER | 435079 | 405 FIRST AVE | BROOKINGS | SD | 57006 | 2010-10-20 | 281 | F | ZKVE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure neurological assessments were completed per policy following a fall for four of four sampled residents (3, 4, 5, and 7) with known head injuries. Findings include: 1. Review of resident 7's nurse's progress notes report revealed she fell at 1:30 a.m. on [DATE]. She was found on the floor with her head under the bed. Assessment of her injuries revealed she had a bruise to her forehead. Her medical record revealed there was no documentation of a neurological assessment (neuro checks) having been completed following that fall. Resident 7 expired on [DATE] in the facility. 2. Review of resident 3's record for falls that would have required neurological assessments according to their facility policy revealed: *An incident report dated [DATE] documented a fall at 10:10 a.m. in the resident's room that resulted in bleeding from the top of her scalp and her left elbow. She complained of pain on the top of her head. The scalp abrasion was cleansed, and ice was applied. Neurological checks per protocol were started. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 11:05 a.m., 11:30 a.m., 12:35 p.m., and 7:00 p.m. On [DATE] assessments were done at 4:00 a.m. and 6:30 p.m. No further documentation was noted on that form. *An incident report dated [DATE] documented a fall at 10:50 p.m. in the resident's bathroom. The resident stated she had hit her head. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 8:50 p.m. and at 11:00 p.m. No further documentation was noted on that form. *An incident report dated [DATE] documented a fall at 4:10 p.m. in the resident's room. She was found on the floor beside her bed on her knees with her head downward. The Neurological Assessment Flow Sheet for that fall noted assessments were done on [DATE] at 4:10 p.m., 10:30 p.m., and 11:30 p.m. On [DATE] an … | 2014-02-01 | ||
| 5141 | 5141 | UNITED RETIREMENT CENTER | 435079 | 405 FIRST AVE | BROOKINGS | SD | 57006 | 2010-10-20 | 279 | E | ZKVE11 | Based on record review, policy review, and interview, the provider failed to ensure care plans were updated and/or revised based on accurate assessments and in a timely manner for five of nine sampled residents (1, 2, 3, 4, and 5) with falls. Findings include: 1. Record review for resident 1 revealed: *A care plan dated 10/5/10 noted the resident was a "high risk faller" and "may use the restroom unattended." *A Fall Risk Assessment Form noted a score of ten or more indicated the resident was at high-risk for falls. *The Fall Risk Assessment Form dated 7/8/10 noted the resident as a high-risk for falls with a score of 14. *The Fall Risk Assessment Form dated 9/30/10 noted the resident as a high-risk for falls with a score of 14. Item B. History of Falls (past 3 months) on that form noted a score of zero for no falls during that period of time. Incident reports in the record noted a total of four falls during that time period occurring on 6/29/10, 7/26/10, 8/7/10, and 9/11/10. On the back of that form a hand written note by licensed practical nurse (LPN) 1 stated "Care team feel that he is not @ (at) high risk b/c (because) he ambulates @ times." Interview on 10/20/10 at 4:30 p.m. with the director of nursing (DON) revealed: *She agreed the 9/30/10 fall risk assessment had not accurately documented the resident's falls for the past three months. *The Care Plan Team consisted of the social worker, LPN 1, physical therapist aide, activities director, case manager, and the DON. *She did not know why the resident was not at high risk for falls as per the comment on the back of the fall risk form. The DON did not remember that Care Plan Team meeting. *She stated the signs in the residents' bathrooms "Must not use restroom unattended" were implemented sometime in May or June 2010. All residents that were at high risk for falls would have that sign in their bathroom. Interview on 10/21/10 at 8:45 a.m. with the quality assurance (QA) coordinator revealed the QA committee notes documented the "Must not use restroom unatten… | 2014-02-01 | ||
| 5142 | 5142 | UNITED RETIREMENT CENTER | 435079 | 405 FIRST AVE | BROOKINGS | SD | 57006 | 2010-10-20 | 282 | D | ZKVE11 | Based on observation, interview, record review, and policy review, the provider failed to ensure care plans were followed, and trained and competent staff provided services to one of nine sampled residents (8). Findings include: 1. Review of resident 8's 4/12/10 care plan revealed an entry that stated: *"High risk faller." *"Do not leave unattended in the bathroom." Review of resident 8's 6/14/10 fall follow-up report revealed: *She did not want to wait for staff to help her off the toilet when she was in the bathroom. *She had started to walk back to her chair from the bathroom when certified nursing assistant (CNA) 7 had opened the door and tried to catch her before she fell . *She stated she knew the staff were "way too busy" to help her. *That fall had resulted in a skin tear to resident 8's right forearm. She also complained of back pain following that fall. Review of information provided to the Department of Health surveyors prior to entering the facility revealed CNA 7 had reported she and the housekeeping/laundry supervisor had been assisting resident 8 to the bathroom. That report stated CNA 7 left the housekeeping/laundry supervisor alone with resident 8. The housekeeping/laundry supervisor had gotten resident 8 "settled" and had left her alone. Per that report it was noted the DON reminded both of those staff members resident 8 was "not to have been left alone in the bathroom as indicated in her care plan." Interview at 7:30 a.m. on 10/20/10 with the housekeeping/laundry supervisor revealed she had not been trained to assist with resident care. She stated if needed she would help residents get a drink of water, put on a sweater, or push them in their wheelchair to their destination. She stated she had not been trained to transfer residents or assist them to the bathroom. She stated she did not remember helping a resident to the bathroom. Interview at 8:20 a.m. on 10/21/10 with the director of nursing (DON) revealed it was her expectation all staff should assist residents as needed. She confirmed the ho… | 2014-02-01 | ||
| 5143 | 5143 | UNITED RETIREMENT CENTER | 435079 | 405 FIRST AVE | BROOKINGS | SD | 57006 | 2010-10-20 | 226 | D | ZKVE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to have a policy in place that ensured an appropriate investigation was implemented following an unwitnessed fall and subsequent death for one of one expired residents (7). Findings include: 1. Review of resident 7's closed record revealed she had been admitted on [DATE] and had expired at the facility on [DATE]. Her record revealed she had fallen at 1:30 a.m. on [DATE]. That fall was unwitnessed and had resulted in a bruise to the resident's forehead. The incident report was not completed until 1:37 a.m. on [DATE]. The resident died at approximately 10:00 a.m. on [DATE]. Notification of that death was made to the Department of Health via facsimile (fax) on [DATE] at 3:26 p.m. Report of that death included a copy of the follow-up report and written statements by staff who responded to resident 7's fall on [DATE]. Report of that death also included date discrepancies that indicated the fall occurred on [DATE] and the death on [DATE]. Review of the above follow-up report revealed: *Resident 7 was found on the floor. *The summary of the interview with the resident indicated the nurse was unable to understand most words. The nurse heard her say "poison," "can't trust," and "pulled." The resident denied having a [MEDICAL CONDITION]. *Her vital signs were taken with a blood pressure of ,[DATE], temperature 98.7 degrees, respirations 24 breaths per minute, and pulse 104 beats per minute. *Her change in physical function was reported as "Hospice." *Her change in cognition/behavior was reported as "Hospice, incoherent most of the time." *The type of injury was reported as a bruise to the forehead. *The location of the incident was indicated as "Found beside bed at 55 degree angle. Soaker pulled at angle, blankets also at angle. Bed up approximately 6 inches from low position." Review of the faxed report also revealed copies of statements received from staff who responded to resi… | 2014-02-01 | ||
| 5144 | 5144 | UNITED RETIREMENT CENTER | 435079 | 405 FIRST AVE | BROOKINGS | SD | 57006 | 2010-10-20 | 514 | F | ZKVE11 | **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 following falls for eight of nine sampled residents (1, 2, 3, 4, 5, 6, 7, and 8). Findings include: 1. Review of resident 7's closed medical record revealed a fall follow-up report had been completed on [DATE] at 1:37 a.m. for a fall that had occurred at 1:30 a.m. on [DATE]. That resident expired at 10:00 a.m. on [DATE] in the facility. Review of the above follow-up report revealed: *Resident 7 had been found on the floor. *The summary of the interview with the resident indicated the nurse was unable to understand most words. The nurse heard her say "poison," "can't trust," and "pulled." The resident denied having a [MEDICAL CONDITION]. *Her vital signs were taken with a blood pressure of ,[DATE], temperature 98.7 degrees, respirations 24 breaths per minute, and pulse 104 beats per minute. *Her change in physical function was reported as "Hospice." *Her change in cognition/behavior was reported as "Hospice, incoherent most of the time." *The type of injury was reported as a bruise to the forehead. *The location of the incident was indicated as "Found beside bed at 55 degree angle. Soaker pulled at angle, blankets also at angle. Bed up approximately 6 inches from low position." Review of resident 7's nurse's notes revealed an entry on [DATE] at 1:42 p.m. regarding a change in a physician's orders [REDACTED]. *"Resident's treatment was done to her toes at which time the resident was attempting to speak with staff and had a smile on her face." *"Speech was mumbled was able to understand resident when asked how she was and resident said fine." *"Color was good, bruise noted to left side of forehead." *"No agitation or anxiety noted." The above entry had no indication of the time that care had been provided. Review of that same nurses' note revealed the following entry: *"Called into resident's room at 1000 (10 a.m… | 2014-02-01 | ||
| 5145 | 5145 | UNITED RETIREMENT CENTER | 435079 | 405 FIRST AVE | BROOKINGS | SD | 57006 | 2010-10-20 | 492 | D | ZKVE11 | Based on observation, interview, policy review, and administrative rule review, the provider failed to follow professional standards and South Dakota Board of Nursing Administrative rule for one of one housekeeper (3) who was performing certified nurse aid (CNA) duties without proper South Dakota state certification. Findings include: 1. Interview on 10/19/10 at 2:15 p.m. with housekeeper 3 revealed: *She had been hired as a housekeeper about one year ago. *She had been a CNA in another state, and her certification was still current in that state. *She had used those CNA skills when working here as a housekeeper. *She had helped out the other CNAs if they needed her. Observation of and interview with housekeeper 3 on 10/20/10 at 2:15 p.m. revealed: *While she cleaned a resident's room the resident needed help into the bathroom. *The housekeeper had helped the resident into the bathroom and out of the bathroom when the resident was done. *The housekeeper stated she had always told another CNA when she had toileted a resident, so the correct documentation was done on the bathroom door toileting form. *For this current incident she stated she would just write it down herself, so she would not have to take time to find another CNA to do it. Interview on 10/20/10 at 4:15 p.m. with the director of nursing (DON) revealed: *The provider had no written policy outlining guidelines of patient care for staff who were CNAs but were hired as housekeepers. *She agreed the housekeeper could use her CNA skills for resident care such as transfers, toileting, and ambulating. *All CNAs needed to have education hours each year to keep their certification current. Interview on 10/21/10 at 10:00 a.m. with the human resources person revealed: *Housekeeper 3 had been hired on 6/6/10. *Housekeeper 3 had been a CNA in another state, and a copy of that state's registry was on file. *Forms needed to be filled out to transfer her certification to South Dakota. *That transfer step had not been done. *Any education for housekeeper 3 would be on… | 2014-02-01 | ||
| 5146 | 5146 | FIRESTEEL HEALTHCARE CENTER | 435109 | 1120 EAST 7TH AVENUE | MITCHELL | SD | 57301 | 2010-10-06 | 514 | D | 2DK211 | Based on record review, policy review, and interview, the provider failed to ensure complete and accurate documentation was maintained for one of one resident (5) following an emergency choking event. Findings include: 1. Review of documentation contained in a 9/20/10 incident report regarding an emergency choking event with resident 5 revealed three registered nurses (RN) (1, 2, and 3) were involved in providing some aspect of care at that time. a. Review of resident 5's 9/18/10 nurses' notes revealed minimal documentation by RN 1 regarding nursing care provided in response to an emergency choking event. Review of those same nurses's notes backdated 9/18/10 but completed on 9/20/10 as a late entry revealed additional comments clarifying the nursing care provided during the above event. Review of those notes revealed timelines of events were generalized and were not specific as to time of occurrence. Interview with RN 1 at 1:57 p.m. on 10/6/10 revealed she had documented at the end of her shift regarding care she had provided to resident 5 during the choking event. She confirmed that documentation was lacking in specifics and accurate timelines. She stated she realized additional documentation was needed for clarification. She stated additional documentation was added on 9/20/10. b. Review of those same nurses' notes revealed no documentation was found by RNs 2 and 3 regarding care provided to resident 5. Interview with RN 2 at 2:45 p.m. on 10/6/10 revealed she was not directly involved with providing care for resident 5 during the above incident. However she did make observations of his status of the care provided. She confirmed she did call the paramedics and was present when they arrived. She stated she did not document her observations in resident 5's nurses' notes. c. Interview with RN 3 at 3:19 p.m. on 10/6/10 revealed he was the house supervisor on 9/18/10. He stated he responded to the call for help and assisted with providing nursing care to resident 5. He confirmed documentation of his actions during th… | 2014-02-01 | ||
| 5147 | 5147 | PRAIRIE VIEW CARE CENTER | 435118 | 401 SOUTH FIRST AVENUE POST OFFICE BOX 68 | WOONSOCKET | SD | 57385 | 2011-01-13 | 431 | D | 193D11 | Based on observation, interview, and policy review, the provider failed to maintain safe and secure storage of medications during two of four randomly observed medication administrations. Findings include: 1. Observation on 01/12/11 from 9:30 a.m. through 9:45 a.m. revealed: *An unlocked medication cart in the 100 wing hallway. *Registered nurse (RN) C was in a resident's room. *RN C came out of the resident's room, returned to the medication cart, and replaced a container of eye drops in the cart without attempting to unlock the cart. *The same unlocked medication cart was moved further down that hallway. *RN C was in a different resident's room. *There were residents and staff moving throughout the 100 wing hallway when the cart was unlocked. 2. Observation on 1/12/11 from 11:15 a.m. to 12:00 noon in the dining room revealed: *The medication cart was unlocked. *RN C had her back to the unlocked medication cart multiple times while she passed medications. *There were residents, visitors, and staff in the dining room while that cart was left unlocked. 3. Review of the provider's medication administration policy from Omnicare of South Dakota revealed: *The medication cart would remain locked when not in direct sight of the person administering medication. *Medications must have been inaccessible to residents and others passing by. Interview on 1/12/11 at 4:20 p.m. with the director of nurses A revealed: *She expected the nurses to lock the medication cart when they were in a resident room. *She considered "direct sight" to be where the nurse could visually see, an eye's view. Interview with RN C on 1/12/11 at 4:45 p.m. revealed: *She had usually locked the medication cart when she was not in attendance. *She had considered the drawers on the cart to have a first lock in place that residents could not open, because she had to slide a hinge to open them. | 2014-02-01 | ||
| 5148 | 5148 | PRAIRIE VIEW CARE CENTER | 435118 | 401 SOUTH FIRST AVENUE POST OFFICE BOX 68 | WOONSOCKET | SD | 57385 | 2011-01-13 | 520 | C | 193D11 | Based on interview and policy review, the provider failed to ensure the medical director was present at the quarterly Quality Assurance (QA) committee meetings for the past year. Findings include: 1. Interview with QA coordinator/licensed practical nurse B on 01/12/11 at 2:30 p.m. revealed: *The physician designated by the provider as a quarterly member of the QA committee was the medical director. *The medical director had only participated in one QA meeting in 2010 on 4/19/10. *QA meetings had been held monthly in 2010 with other committee members. *She was aware there was to be a physician present at the QA meetings at least quarterly. *She agreed the physician had only been present for one QA meeting in 2010. Interview with director of nurses A on 01/12/11 at 2:40 p.m. revealed: *She was aware there was to be a physician present at the QA meetings at least quarterly. *She agreed the physician had only been present for one QA meeting in 2010. Review of the provider's undated Clinical Guideline: QA & A Committee revealed the medical director would be in the committee membership. Review of the provider's Medical Director Agreement dated 05/01/04 revealed: *The duration of the agreement was ongoing. *The medical director would participate in quality assurance as requested. *An undated, handwritten, and initialed notation had been made on the agreement that added QA committee participation. | 2014-02-01 | ||
| 5149 | 5149 | PRAIRIE VIEW CARE CENTER | 435118 | 401 SOUTH FIRST AVENUE POST OFFICE BOX 68 | WOONSOCKET | SD | 57385 | 2011-01-13 | 371 | E | 193D11 | Based on observation, interview, and policy review, the provider failed to ensure proper sanitary procedures were followed during the serving process for two of two observed meals and for scoops used in food preparation. The staff failed to: *Place the scoops in the food in a manner to prevent cross-contamination during the serving process. *Place scoops in food storage bins to prevent cross-contamination. *Prevent cross-contamination by not cleaning work surfaces between preparation of different foods. *Prevent cross-contamination of the thermometer used to check the temperatures of the food as it was prepared. *Wash hands and change gloves appropriately between tasks to prevent cross-contamination. *Handle ready-to-eat foods in a safe and sanitary manner. *Have hair restrained effectively. Findings include: 1. Observation during the supper meal on 1/11/11 from 4:05 p.m. until 6:00 p.m. revealed dietary staff E during the supper meal preparation: *Served taco casserole and stewed tomatoes on to a plate for a staff member. *Placed the two soiled serving utensils on a paper towel, and the food soaked through to the counter top. *Used the soiled serving spoon to remove enough taco casserole to prepare the pureed servings. *Placed the serving spoon on the soiled paper towel on the counter again. *Placed the serving spoon in the taco casserole on the steam table, and then used it to serve the casserole to the residents. *The soiled ladle for the stewed tomatoes was moved to the lid of the container that held the stewed tomatoes. *That lid had been touched by the hot pads and the staff hands during meal preparation. *The hot pads had been touched by gloved and ungloved hands and had been placed on multiple counter tops in the kitchen during the meal preparation. *The ladle was then placed in the stewed tomatoes and remained there while the meal was served. 2. Observation on 1/11/11 at 4:25 p.m. revealed a scoop was lying in the flour bin with the handle in the flour. 3. Observation on 1/11/11 at 2:15 p.m. revealed die… | 2014-02-01 | ||
| 5150 | 5150 | WINNER REGIONAL HEALTHCARE CENTER | 435056 | 805 E 8TH ST | WINNER | SD | 57580 | 2011-12-14 | 280 | E | IY0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure: *The care plan for 1 of 1 sampled resident (3) was completed to show essential information for the care of the resident. *Care plans for 5 of 13 sampled residents (2, 8, 10, 12, and 13) were followed for residents receiving restorative care. Findings include: 1. Review of resident 3's record revealed he was admitted on [DATE]. Review of a 7/28/11 hospital discharge summary revealed he had a pacemaker placed in 2009. Review of resident 3's cumulative [DIAGNOSES REDACTED]. Review of resident 3's current falls care plan revealed the pacemaker locater box had been checked. There had been no recorded goals or approaches documented for the pacemaker on the falls care plan. Review of resident 3's comprehensive care plan dated 11/15/11 revealed there:*Was no focus area for a pacemaker. *Were no goals or interventions about the care he should have been provided in relation to the pacemaker Interview on 12/14/11 at 9:30 a.m. with registered nurse (RN) K regarding resident 3 revealed: *She stated his condition had been "grave" at the time of his admission. *She agreed the pacemaker should have been included in his care plan. 2. Review of residents 2, 10, and 12's care plans revealed they had not been followed as written for restorative therapy. Refer to F281, findings 1.a, b, and c. 3. Review of resident 8's 8/31/11 care plan revealed she was to have received restorative care two to four times a week. Review of resident 8's November 2011 restorative care daily documentation revealed: *She had received only three treatments. *Her treatment had not been completed five times due to her sleeping or she had attended an activity. Review of resident 8's December 2011 restorative care daily documentation from 12/1/11 through 12/12/11 revealed she had received four treatments. 4. Review of resident 13's 5/27/11 care plan revealed she was to have received restorative care four to six times a wee… | 2014-01-01 | ||
| 5151 | 5151 | WINNER REGIONAL HEALTHCARE CENTER | 435056 | 805 E 8TH ST | WINNER | SD | 57580 | 2011-12-14 | 281 | E | IY0E12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure policy and professional standards were followed when medications were administered by gastrostomy tube ([DEVICE] (a tube placed directly into the stomach)) for one of one resident (20) observed for [DEVICE] medication administration. Findings include: 1. Observation on 1/18/12 at 2:25 p.m. of licensed practical nurse (LPN) M administering medications by [DEVICE] to resident 20 at the nurse's station revealed the LPN: *Removed [MEDICATION NAME] solution from the medication room refrigerator and measured 20 milliliters (ml) into a medication cup. *Then opened a dantrolene 100 milligram (mg) capsule and sprinkled the contents on the surface of the [MEDICATION NAME] solution. *Then crushed a [MEDICATION NAME] 2 mg tablet and sprinkled the contents on the surface of the [MEDICATION NAME] solution. *Did not make any attempt to dissolve the dantrolene and [MEDICATION NAME] into the [MEDICATION NAME] solution or to warm the [MEDICATION NAME] solution. LPN M then went to resident 20's room to administer the above medications. After obtaining approximately 300 ml of water from the resident's faucet she: *Listened with the stethoscope against the abdominal wall as she inserted approximately 30 ml of air into the [DEVICE]. *Then without flushing the [DEVICE] with water, she administered the above combined medications directly into the syringe attached to the [DEVICE]. At the time of administration the dantrolene and [MEDICATION NAME] were both in powder form and floating on the surface of the [MEDICATION NAME] solution. *She added approximately 40 ml of water to the medications that were in the syringe. The medications and water did not appear to flow freely through the [DEVICE]. She then used the syringe plunger to push the contents into the [DEVICE]. *She added 40 to 60 ml of water to the syringe six different times, each time using the syringe plunger to push the content… | 2014-01-01 | ||
| 5152 | 5152 | WINNER REGIONAL HEALTHCARE CENTER | 435056 | 805 E 8TH ST | WINNER | SD | 57580 | 2011-12-14 | 224 | G | IY0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure one of one unlicensed assistive personnel (UAP) (B) in the special care unit provided care without mistreating one of one resident (18). Findings include: 1. Observation on 12/14/11 at 10:30 a.m. during care for resident 18 provided by UAP B revealed: *The UAP put gloves on her hands after she had washed them for less than 15 seconds. *She entered resident 18's room. *She told the resident she had eye drops to administer. *She opened the eye drop bottle and approached the resident. *The resident began calling out repetitively she was "going to die-don't-no", and she had shut her eyes tightly. *The UAP attempted to open the resident's right eye with her hands as the resident resisted by pushing away with her hands and saying no. *The resident's eye had remained closed, and the UAP applied an eye drop that landed on the resident's closed eyelids. *The UAP then pulled the resident's left lower eyelid down with her fingers, so the eyelashes touched the resident's skin under her eye. *The resident continued to resist as before. *The UAP then tried to put an eye drop in the resident's eye and jabbed the resident in the eye with the end of the eye drop applicator as the resident thrashed about trying to resist the eye drops. *The resident cried out "ouch" when that happened. *The UAP stated to the resident "Oh, you're okay." *The eye drop rolled down the resident's cheek. *The UAP then put down the eye drops and picked up a tube of [MEDICATION NAME] ointment. *With the same gloves applied that ointment to the resident's left heel. *She then put down the ointment, picked up a jar of [MEDICATION NAME] cream, used her gloved hand and removed cream, and applied it to the resident's left heel. *She then put that jar down and used a wet wipe to cleanse under the resident's breasts. *She picked up another jar of [MEDICATION NAME] cream, dipped her gloved fingers into that cre… | 2014-01-01 | ||
| 5153 | 5153 | WINNER REGIONAL HEALTHCARE CENTER | 435056 | 805 E 8TH ST | WINNER | SD | 57580 | 2011-12-14 | 371 | F | IY0E11 | Based on observation, interview, and policy review, the provider failed to ensure proper sanitary procedures were followed while serving two of two observed meal services. The staff failed to: *Clean the food testing thermometer after each use to prevent cross-contamination. *Wash hands between glove changes to prevent cross-contamination. Findings include: 1. Observation on 12/13/11 at 11:30 a.m. of cook F revealed she sanitized the probe on the food testing thermometer with an alcohol swab and proceeded as follows: *tested the temperature of the meatballs. -Reused the same alcohol swab to wipe the thermometer probe. *Took the temperature of the scalloped potatoes. -Used a clean alcohol swab to sanitize the thermometer probe. *Took the temperature of the mashed potatoes. -Reused the same alcohol swab to sanitize the thermometer probe. *Took the temperature of the super mashed potatoes. -Reused the same dirty alcohol swab to sanitize the thermometer probe. 2. Observation on 12/13/11 from 11:45 a.m. through 12:30 a.m. of cook G revealed she changed her gloves two times during the meal service. She did not wash her hands after she took off her soiled gloves and before she had put on clean gloves. 3. Observation on 12/13/11 at 12:10 a.m. revealed dietary assistant J changed gloves. She did not wash her hands before she put on clean gloves. 4. Observation on 12/13/11 at 4:45 p.m. of cook H revealed she sanitized the probe on the food testing thermometer with an alcohol swab and proceeded as follows: *tested the temperature of the hamburger patty. -Reused the same alcohol swab to sanitize the thermometer probe. *tested the temperature of the French fries. -Reused the same alcohol swab to sanitize the thermometer probe. *tested the temperature of the vegetables. -Reused that same dirty alcohol swab to sanitize the thermometer probe. *tested the temperature of the pureed meat. -Reused that same dirty alcohol swab to sanitize the thermometer probe. *tested the temperature of the pureed vegetable. -Again reused that same … | 2014-01-01 | ||
| 5154 | 5154 | WINNER REGIONAL HEALTHCARE CENTER | 435056 | 805 E 8TH ST | WINNER | SD | 57580 | 2011-12-14 | 441 | E | IY0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview, and policy review, the provider failed to ensure proper handwashing and glove use was used during randomly observed: *Resident care for 2 of 2 resident (2 and 18) . *Medication administrations for 1 of 11 residents (2). Findings include: 1. Observation on 12/13/11 at 10:45 a.m. revealed restorative nurse aide (NA) E: *Wore gloves while she cleaned resident 2's bottom after a bowel movement as he was assisted off the toilet. *Pulled his slacks up. *Grabbed the walker with her hands and placed it in front of him. *Touched his coat. *Assisted him into the easy chair. *Removed her gloves. *Without washing her hands placed a blanket on him. *Placed his call light within reach. *Opened the room door. *Pushed a laundry cart to the soiled utility room. *At that time washed her hands at the nurse's desk. 2. Observation of care for resident 18 revealed improper handwashing and glove use during that care. Refer to F224, finding 1. 3. Random observation on 12/14/11 at 9:45 a.m. during medication pass revealed licensed practical nurse (LPN) C; *Entered resident 2's room and put gloves on without first washing her hands. *Applied ointment to the resident's toe with her gloved hand. *Removed the gloves before she left the room. *Did not wash her hands when she left the room. *Opened the room door. *Walked to the medication cart located at the nurse's desk and removed multiple packages of medications from her pockets and placed them in the medication cart. *Then she had washed her hands. Review of the provider's revised May 2007 handwashing/hand hygiene policy revealed: *When gloves were removed hands were to have been washed. *Gloves were to be removed and hands washed before moving from a soiled area to a clean area. *Handwashing was to have been done before and after care had been given to the resident. *Handwashing was to have been done between cares on different body sites on the same resident. *Hands were to be washe… | 2014-01-01 | ||
| 5155 | 5155 | GOOD SAMARITAN SOCIETY DE SMET | 435074 | 411 CALUMET AVENUE NW | DE SMET | SD | 57231 | 2010-10-14 | 279 | D | 0Q5G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the provider failed to ensure the plan of care for 2 of 12 sampled residents (2 and 9) contained sufficient information to meet the residents' needs. Findings include: 1. Random observations from 10/13/10 to 10/14/10 revealed resident 2 was in his wheelchair with a fastened seatbelt. Record review for resident 2 revealed: -There was no documentation in the interdisciplinary progress notes to suggest a seatbelt was indicated. -The last physical restraint assessment in the chart was dated 2/11/09. -There was no physician's order to resume the seatbelt. -A physician's order dated 3/4/10 to discontinue the seatbelt. Review of resident 2's care plan dated 7/21/10 revealed no goals or interventions related to the use of the seatbelt. Interview on 10/14/10 at 8:50 a.m. with the director of nursing (DON) revealed: -The resident had changed wheelchairs multiple times due to comfort and positioning issues. -The wheelchair the resident was in during the survey was the original wheelchair resident 2 had started with. -She had not documented the wheelchair changes that had been made or the resident's ability to remove the seatbelt. -A physician's order to resume the seatbelt should have been obtained. -No goals or interventions had been made on the care plan for the resident's use of the seatbelt. -It would have been her expectation for goals and interventions to be listed on the care plan for resident 2's seatbelt use. Review of the provider's physical restraints procedure revised February 2005 revealed the following should have been completed: -The physician should have been contacted. -A physician's order for the seat belt should have been obtained. -An informed consent for permission to use the seat belt should have been obtained. -The resident's care plan should have included the reason for the restraint, required monitoring, and a measurable goal related to the rationale for its use. -There should … | 2014-01-01 | ||
| 101 | 101 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2019-05-23 | 684 | D | 1 | 0 | LF7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to ensure necessary care and services was provided for two of twelve sampled residents (52 and 56) as evidenced by: *Not giving a timely opportunity to use a toilet or commode and not having a repositioning schedule in place to prevent decline for resident 52. *Not investigating a skin tear of unknown origin and not providing an ordered as needed treatment to a swollen surgical site for resident 56. Findings include:1. Observation on 5/22/19 at 1:14 p.m. of resident 52 in her room revealed:*She was alone in her room sitting in her wheel chair (w/c) with her back to the door. *There was an over bed table in front of her with her lunch on it.*There was a large wet area on the floor behind her w/c that was yellow colored.*There was a bubble cup on the floor.*She had gray sweat pants on.*Those sweat pants were wet between her legs where she was sitting.*The left front hip crease area of her sweat pants were also wet.Observation and interview on 5/22/19 at 1:18 p.m. of resident 52 in her room revealed:*Certified nurse aide (CNA) M walked into the room.*She noticed the wet area on the floor and to the resident's sweat pants.*She stated she had offered to lay her down at approximately 10:00 a.m. so she could change her brief.-The resident had refused.*She used her Walkie Talkie to ask for assistance to the room.*She left and returned with a mop and bucket.*She mopped up the wet area on the floor behind her w/c.*She picked the bubble cup up from the floor and put it on her overbed table.*She went into the bathroom and without washing her hands she put on gloves.Observation and Interview on 5/22/19 at 1:34 p.m. of resident 52 in her room revealed:*CNAs H and I entered the room.*CNA I stated that he and another CNA had changed the resident's brief at 11:50 a.m.-She had had a bowel movement (BM).-When asked, CNA I stated that he had documented that brief change.*CNA… | 2020-09-01 |
| 103 | 103 | ROLLING HILLS HEALTHCARE | 435035 | 2200 13TH AVE | BELLE FOURCHE | SD | 57717 | 2019-05-23 | 689 | D | 1 | 0 | LF7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and policy review, the facility failed to ensure one of one sampled residents (60) who was totally dependant was transferred safely. Findings include: Review of resident 60's 4/25/19 Minimum Data Set (MDS) assessment revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was zero indicating her cognition was severely impaired. *She required the extensive assistance of two staff for: -Bed mobility. -Dressing. -Toilet use. *She was totally dependent on two or more staff for transfers. Interview of 5/21/19 at 8:51 a.m. with resident 60's representative revealed: *She felt the lift used to transfer her mother caused pain. *There were two men who worked in the evening who would help get her mother to bed. -She could not remember their names. *She had asked them to pick her mother up and move her from the chair to the bed and vice versa. *She had witnessed them moving her in this manner, without the lift and believed that it was easier on her mother. Interview on 5/22/19 at 3:19 p.m. with certified nursing assistant (CNA) H regarding resident 60 revealed she: *Required a full lift transfer. *Denied seeing signs or symptoms of pain for the resident during transfer. *Denied seeing anyone transfer her without a lift, stating it would be unsafe. Interview on 5/22/19 3:22 p.m. wit CNA I regarding resident 60 revealed he had: *Met resident 60's representative. *Never seen or heard of anyone transferring her without a lift. *Would not transfer the resident without a lift because it would jeopardize his job. Interview of 5/22/19 at 2:41p.m. with the administrator and the director of nursing (DON) regarding resident 60 revealed: *They would not be surprised if the family asked for the resident to be transferred without the lift. *They would be surprised if the staff would transfer her without the lift. *They had not heard of this happening. *They did not transfer people without the tot… | 2020-09-01 |
| 136 | 136 | TEKAKWITHA LIVING CENTER | 435038 | 6 E CHESTNUT | SISSETON | SD | 57262 | 2018-01-31 | 689 | E | 1 | 0 | NOYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to ensure: *Timely preventative maintenance to include checking lift clips for one of three total mechanical lifts (2) to prevent a fall for one of one sampled resident (1). *Staff education and training for all direct care staff including four of four interviewed certified nurse assistants (CNA) (A, B, C, and D) about proper usage, sling selection, and appropriate maintenance of total mechanical lifts when used with sampled residents 1, 4, and 5. Findings include: 1. Review of resident 1's 1/18/18 South Dakota Department of Health (SD DOH) event report revealed: *Certified nursing assistants (CNA) D and F had been transferring the resident into her wheelchair with the total mechanical lift. *The sling hooked on the right front hook slide off Hoyer hook when sling was pulled back to sit resident straight into her w/c (wheelchair). *The resident fell forward and hit the right side of her head on the floor. *The lock on the right hook did not go into lock position causing the right sling hook to slide off Hoyer. *The equipment malfunction was written up for the maintenance department, and the Hoyer lift had been removed from the floor. *The report had been completed by licensed practical nurse [NAME] Observation on 1/30/18 at 3:50 p.m. in the 100 hallway revealed on Hoyer lift 4 one of four clips was broken. Interview on 1/31/18 at 9:00 a.m. with CNA D regarding resident 1's fall out of the lift revealed: *She had been employed at the facility for approximately sixteen years. *They had been using the total mechanical lift labeled 2. *All four clips had been broken on the lift prior to transferring resident 1 on 1/18/18. *The clips had been broken for awhile, but she was not sure how long they had been broken. *She had not reported the broken clips to maintenance. *She had not had training on proper use and maintenance of the lifts since she had been employe… | 2020-09-01 |
| 137 | 137 | TEKAKWITHA LIVING CENTER | 435038 | 6 E CHESTNUT | SISSETON | SD | 57262 | 2018-01-31 | 867 | E | 1 | 0 | NOYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and policy review, the provider failed to identify concerns with multiple falls and to implement an effective performance improvement plan (PIP) and quality assurance program. Findings include: 1. Review of the provider's event summary report from 11/1/17 through 1/30/18 revealed there had been thirty-two falls involving sixteen residents. Interview on 1/31/18 at 12:25 p.m. with the quality assurance program nurse revealed: *She had been in the role for about two years. *She had received some training from the state quality assurance coordinator at the beginning. *She was also the infection control nurse, the grievance official, and worked on the floor two days a week. -Today she had been scheduled to work in the office and not on the floor. *Relevant to falls, she had taken over completing post fall huddle reports because CNAs and other staff were not completing them. -They had not looked at the data collected to determine staffing issues or environmental issues. -Interventions were implemented after the fall had occurred. -The falls PIP had been going on since (MONTH) (YEAR). *Other PIP projects she was currently working on included: -Pressure ulcers - no date of initiation. -[MEDICATION NAME] screening - no date of initiation. -Food temperature recording was initiated in (MONTH) (YEAR). --She was unsure why the dietary manager was not involved with this PIP. -Perineal and catheter care was initiated in (MONTH) (YEAR). -Self-administration of medications was initiated in (MONTH) (YEAR). *She had been in charge of all the above PIPs. Interview on 1/31/18 at 1:00 p.m. with the director of nursing revealed they had not had other department heads involved in the quality assurance PIP process. Review of the provider's undated Quality Assurance Performance Improvement policy revealed goals were to incorporate quality process assessment, evaluation, and improvement planning for all systems sustaining of improve… | 2020-09-01 |
| 149 | 149 | TEKAKWITHA LIVING CENTER | 435038 | 6 E CHESTNUT | SISSETON | SD | 57262 | 2017-11-28 | 585 | E | 1 | 0 | QFLH11 | > Based on interview and policy review, the provider failed to have a facility based system in place to document grievances brought to their attention by staff, residents, or family members. Findings include: 1. Interview on 11/28/17 at 11:00 a.m. with an anonymous family member revealed she had been yelled at by a staff member a few weeks back. While she could not recall the name of the staff member who had yelled at her, she identified another staff member who had witnessed the event. Interview on 11/28/17 at 11:15 a.m. with an anonymous staff member revealed: *Earlier in the month she had overhead certified nursing assistant (CNA) C getting loud with the above family member and resident. *She had been walking down the hall towards the residents' rooms when the voices started to get loud. *She had walked into the room and heard CNA C yelling at the family member. *She had reported the incident to the charge nurse. *She was unable to remember who the charge nurse was that night. Interview on 11/28/17 at 1:30 p.m. with the social services designee and the director of nursing (DON) regarding their grievance process revealed they: *Had no way of tracking grievances. *Were unable to provide what grievances had been received since 9/18/17, and how those grievances were resolved. *Stated grievances were handled on an individual basis but could not provide what grievances they had looked into and resolved. Interview on 11/28/17 at 1:45 p.m. with the administrator revealed: *They currently had a grievance form that staff should have been filling out but were not. *They were changing the process but had no timeline for when that would be implemented. *The DON had received a note under her door on 11/27/17 regarding CNA C and her behavior being inappropriate towards family and residents. -The note had not been signed. *They were waiting to talk to CNA C on 11/29/17, as that was the next shift she was scheduled to work. *They had not started an investigation into the matter. *They had not documented that as a grievance. Re… | 2020-09-01 |
| 150 | 150 | TEKAKWITHA LIVING CENTER | 435038 | 6 E CHESTNUT | SISSETON | SD | 57262 | 2017-11-28 | 610 | E | 1 | 0 | QFLH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and policy review, the provider failed to thoroughly investigate falls for two of two sampled residents (1 and 4). Findings include: 1. Review of resident 1's 10/6/17 South Dakota Department of Health (SD DOH) event reporting form revealed: *The fall had occurred at 4:30 a.m. *The resident's wife had received a call at home from the resident asking her to contact the nurses in the facility, as he needed help. *Staff received the call from the wife, and they found him sitting on the floor. *Resident first stated he was sitting on his wheeled walker and fell asleep and woke up to falling onto the floor. *Then later stated that he was trying to move his wheelchair to the hallway and fell . *His left eye was swollen. *His wife had taken him to the hospital where he was admitted for weakness, [MEDICAL CONDITION], and fall with periorbital hematoma. *They will encourage resident to utilize his wheelchair (if still appropriate) and walker and not to walk on his own. *Will keep call light in reach and make sure his cell phone is on his person, so if not within call light reach able to make contact with staff or wife. *The administrator's name had been on the final investigation conclusionary summary. *There had been no documentation regarding the following investigation areas: -Interviews conducted with the wife or staff members who had been working. -Where the call light had been located. -The last time he had been checked on. -What level of assistance he required. -If the care plan had been followed. -What the environment looked like upon entering the room. -If he had been assisted to bed and who last worked with him. -If there had been any medication changes. 2. Review of resident 4's 11/19/17 South Dakota Department of Health (SD DOH) event reporting form revealed: *The fall had occurred at 11:30 a.m. *Resident prone on floor beside tipped recliner. *He had complained of pain to his left eye brow where an abra… | 2020-09-01 |
| 151 | 151 | TEKAKWITHA LIVING CENTER | 435038 | 6 E CHESTNUT | SISSETON | SD | 57262 | 2017-11-28 | 658 | D | 1 | 0 | QFLH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and policy review, the provider failed to ensure professional standards of practice were followed for one of one sampled resident (1) for: *Receipt, transcription, clarification, implementation, re-evaluation, and follow-up to physician's orders. *Appropriate nurse documentation of medication when not readily available in the facility versus refused by the resident. Findings include: 1. Review of resident 1's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Disorder of the kidney. -Muscle weakness. -Unspecified dementia. -[DIAGNOSES REDACTED]. -Essential hypertension. *He had fallen on 10/6/17 at 4:30 a.m. Review of resident 1's 10/6/17 nursing progress note revealed: *At 4:30 a.m. Received call from resident's wife asking for him to be checked on. -Resident called wife from personal cell phone and told her he needed help. -Resident checked on and found sitting on the floor. -Resident first stated that he was sitting on his wheeled walker and fell asleep but woke up as he was falling on the floor. -Then later stated that he was trying to move his wheelchair to the hallway and fell . -Noticed left eye was swollen. -No other injuries noted. -Vitals, range of motion, and neuro (signs) checked. -Doctor and spouse notified of event. --There had been no documentation regarding the recommendation from the physician regarding the resident hitting his head. *At 9:39 a.m. Residents wife here with resident this AM. States that she called (physician's name) regarding fall this AM and plans to take resident to the (hospital name) ER (emergency room ) and to see (physician's name). *At 10:05 a.m. Resident to (hospital name) ER via private vehicle accompanied by wife. Meds (medication) sent with. *At 11:47 a.m. (Physician's name) updated that resident was taken to (hospital name) ER to see (another physicia… | 2020-09-01 |
| 160 | 160 | AVANTARA NORTON | 435039 | 3600 SOUTH NORTON AVENUE | SIOUX FALLS | SD | 57105 | 2018-03-13 | 600 | H | 1 | 0 | Z0T511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and policy review, the provider failed to: *Provide necessary care in services resulting in neglect and resident-to-resident altercations for two of two sampled closed resident record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit (MCU). *Implement a resident-specific care plan that included evaluations and revisions of interventions to prevent abuse and neglect for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. *Provide supervision and monitoring of the delivery and implementation of care for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. *Ensure effective communication between nursing and direct care staff and health care providers regarding physical and verbal abuse for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. *Contact the primary physician at the time of an acute change in condition that required the plan of care to be revised to meet the residents' needs in a timely manner for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. *Ensure staff responded professionally to medical and psychiatric emergencies for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. *Ensure thorough orientation upon hiring for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Review of a So… | 2020-09-01 |
| 161 | 161 | AVANTARA NORTON | 435039 | 3600 SOUTH NORTON AVENUE | SIOUX FALLS | SD | 57105 | 2018-03-13 | 609 | E | 1 | 0 | Z0T511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and policy review, the provider failed to: *Ensure the South Dakota Department of Health had been notified of reportable incidents for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment. *A thorough investigation had been completed for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired with reportable incidents. Findings include: 1. Review of resident 1and 2's closed records and residents 3, 4, and 5's active medical records and investigation reports revealed: *The residents had been subject to falls and resident-to-resident altercations. *The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). *All reviewed events had not been thoroughly investigated to: -Discover the cause of the event. -Implement safeguards to prevent further potential abuse. 2. Review of the provider's 8/17/17 Care Plans - Comprehensive policy and procedures revealed: *An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. *1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive for each resident that identifies the highest level of functioning the resident may be expected to attain. *3. Each resident's comprehensive care plan is designed to: -a. Incorporate identified problem areas; -b. Incorporate risk factors associated with identified problems; -d. Reflect the resident's expressed wishes regarding care and treatment goals; -g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; *6. Identifying problem areas and their causes, and developing … | 2020-09-01 |
| 162 | 162 | AVANTARA NORTON | 435039 | 3600 SOUTH NORTON AVENUE | SIOUX FALLS | SD | 57105 | 2018-03-13 | 610 | H | 1 | 0 | Z0T511 | > Based on record review, interview, and policy review, the provider failed to ensure a thorough investigation had been completed and documented for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired and had been subject to resident-to-resident altercations. Findings include: 1. Review of resident 1, 2, 3, 4, and 5's medical records revealed: *They had been subject to resident-to-resident altercations. *Thorough investigations had not been documented and maintained. *The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). Refer to F600, F609, F657, F658, F726, F744, F745, and F842. | 2020-09-01 |
| 163 | 163 | AVANTARA NORTON | 435039 | 3600 SOUTH NORTON AVENUE | SIOUX FALLS | SD | 57105 | 2018-03-13 | 657 | E | 1 | 0 | Z0T511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and policy review, the provider failed to ensure care plans were updated to reflect individual needs and interventions for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: 1. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed:*For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-six of thirty days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-six of thirty days. --Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behaviors. *For (MONTH) (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. Of those days the wandering behavior had: --Placed her at significant risk for twenty-one of thirty-one days. --Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. -The 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. *For (MONTH) 1 through (MONTH) 15, (YEAR): -6:00 a.m. through 6:30 p.m. entries revealed: --She had wandered in hallways or other residents' rooms for nine of fifteen days. Of those days the wandering behavior had: --Significantly intruded on the privacy or activities of others for nine of fifteen days. -On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. --There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. -The (MONTH) 1 to 15 from 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. --There was no further documentation in the medical record regarding what had prompted th… | 2020-09-01 |
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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 );