Avera Morningside Heights Care Center

Based on interview and document review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program provided supervision for 1 of 1 infection preventionist (IP), to identify a thorough infection control surveillance program included surveillance of all employee illness. QAPI also failed to ensure employee surveillance was appropriately delegated to personnel in employee health (EH) who were not certified in infection control. This had the potential to affect all 74 residents. Refer to F880 and F882Findings include: Review of the current, facilities infection control surveillance for employees identified the facility utilized corporate employee health to track employee illness. The IP failed to have any oversight for employee illness and relied on corporate employee health (EH) to provide facility employee surveillance. There was no documentation to support the IP was made aware by EH daily of staff call-ins, had oversight to ensure staff would remain out of work, used that daily data to correlated staff illness to potential resident illness, and ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to have a current, ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that included all staff. This had the potential to affect all 74 residents. Refer to F882 and F868 Findings include: Review of facility infection control surveillance identified only resident illness surveillance had been completed at the facility. Interview on 12/2/25 at 4:10 p.m., with the infection preventionist (IP) identified employee's call central employee health (EH) when ill to report their symptoms, EH then provides the employee general guidelines of when they can return to work. The manager will get a call that the staff called in ill and when they can return to work based on the employee's illness. If employee heath identified a trend in employee illness, then EH would reach out to notify her so she could compare with the facility residents to see if there was any correlation. She revealed that she did not keep a record of employee illness only EH had that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate oversight of the infection control (IC) program that included employee surveillance of all employees. This had the potential to affect all 74 residents. Refer to F880 and F868 Findings include: Review of facility infection control surveillance identified only resident illness surveillance had been completed at the facility. Employee surveillance had not been included. Interview on 12/2/25 at 4:10 p.m., with the infection preventionist (IP) identified employee's call central employee health (EH) when ill to report their symptoms, EH then provides the employee general guidelines of when they can return to work. The manager will get a call that the staff called in ill and when they can return to work based on the employee's illness. If employee heath identified a trend in employee illness, then EH would reach out to notify her so she could compare with the facility residents to see if there was any correlation. She revealed that she did not keep a record of employee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R32 R32's October 2024, Medication Administration Record (MAR) identified R32 was to be administered erythromycin 0.5% ophthalmic eye ointment. Observation and interview on 10/30/24 at 8:12 a.m., with licensed practical nurse (LPN)-A during medication administration identified she put on gloves (donned) gloves, opened the drawer of the medication cart, removed R32's blister packs of medication, and placed them into a medication cup. With her gloved hands, LPN-A placed the blister packs into the drawer, opened another drawer and took out a tube that contained erythromycin (antibiotic) eye ointment. LPN-A then closed the drawer, locked the medication cart, and walked down to R32's room. LPN-A knocked on the door, opened it, sat the medication on the overbed table, and administered the eye ointment. LPN-A did not wash hands or change gloves prior to administering eye ointment after touching other surfaces. LPN-A agreed with the above findings and identified she should have removed her old gloves, washed her hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure appropriate infection control technique was followed during 1 of 1 meal service. This had the potential to affect all 20 residents residing on the Gardens unit. Findings include: Observation on 10/28/24 of the supper meal served on the Gardens unit identified at: 1) 5:30 p.m., it was noted The meal being served by cook-A. During serving of the meal, cook-A demonstrated multiple incidents of potential cross-contamination and lack of appropriate hand hygiene as he plated the meal for residents. Cook-A was noted to have facial hair that was uncovered as he was dishing food items from the steam table and moving about the kitchenette, obtaining various food items and placing them onto plates. 2) 5:32 p.m., cook-A returned to the steam table wearing the same gloves with which he had opened cabinets to retrieve serving items, and opened the refrigerator and freezer doors to obtain items to place onto trays. Upon returning to the steam…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was provided to 1 of 1 resident (R21) prior to mealtime and during morning cares and required staff assistance. Findings include: R21's quarterly Minimum Data Set (MDS) identified R21's cognition was severely impaired, she had continuous inattention and disorganized thinking present. She required set up assistance with eating and was dependent on staff for all other cares. R21 was incontinent of bowel and bladder. R21 had diagnoses of Alzheimer's disease, dementia, anxiety, and depression. R21's 5/10/24, care plan identified she had difficulty making needs known and she was rarely understood. She has a diagnosis of Alzheimer's disease and and Vascular dementia. R21 required her food to be cut up and she needed staff assistance. The nurtion assessment noted resident should not have silverware. Interview on 10/28/24 at 4:21 p.m., with family member (FM)-D identified there were concerns R21 was not getting her fingernails trimmed. FM-D states that R21 ate with her hands and at times had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to have evidence of a Performance Improvement Project (PIP) which identified facility specific high risk or problem-prone areas, develop an action plan to correct the identified areas of concern, and to ensure the committee participated in the development and oversight of the systems. This had the potential to affect the quality of care and quality of life for all 72 residents in the facility. Findings include: Interview and record review of minutes with the Quality Assurance (QA) coordinator, for the last 3 quarters; March 16, 2023; April 20, 2023; May 18, 2023, June 15, 2023, July 20, 2023; September 21, 2023, and October 19, 2023, identified the facility had failed to identify facility specific problems or areas of concern, develop action plans, and implement systems with documented QAPI committee oversight. Interview on 11/28/23 at 2:15 p.m., with the QA coordinator reported QA education is provided to all staff annually by online education related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure the hot steam table was separated from the resident's area in 1 of 3 kitchenettes observed (Gardens resident dining area) placing residents at risk for potential burns. Findings include: Review of current resident's roster residing in the Gardens wing of the facility identified 19 resident total, with 14 residents identified with cognitive impairment and 2 at risk for wandering with Wander Guard devices in place. Observation on 11/27/23 at 12/21 p.m., in the Gardens kitchenette dining area identified a steam table used to hold food at a hot holding temperature while serving residents was against the wall. The steam table and surrounding area lacked any barrier between it and the residents. Observation on 11/27/23, at 12:44 p.m., dietary aid (DA)-A shut off steam table and left area, no other staff were present. Steam table remained very hot to touch. The Garden's dining area was open to resident common areas lacking any barrier or door to ensure resident could not wander into the area. Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure the steam table where resident meals were served had a sneeze guard to protect food from being contaminated by nearby staff. This had the potential to effect all 12 residents who ate in the Gardens dining area. Findings include: Observation on 11/27/23 at 12:21 p.m., in the Garden dining area identified a steam table against the wall. The steam table lacked a sneeze guard to help reduce the risk of contamination from nearby staff or residents, and there was no separation device used to keep staff or residents any distance away. Dietary aide (DA)-A was observed facing the steam table and dishing food onto plates and placing on a cart, either he or a nursing assistant would take the cart and pass to the residents. Other staff were observed standing near the steam table while DA-A was dishing food. Interview on 11/29/23 at 1:57 p.m., with administrator identified he was not aware that they needed a sneeze guard but agreed that this could pose a risk for contamination. He identified that going forward they would ensure a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review the facility failed to follow manufacture's instructions for cleaning and disinfecting 2 of 2 Master Care Air Jetted tubs located on the First floor. This had the potential to affect 24 of 34 residents, ( R1, R3, R4, R5, R8, R11, R12, R13, R15, R17, R18, R21, R23, R24, R27, R33, R35, R36, R37, R41, R46, R47, R51, and R60) who utilized the two tubs. The facility also failed to ensure staff followed policy and procedure for donning and doffing personal protective equipment (PPE) following use with a resident who was on precautions and failed to sanitize a Hoyer lift following use with a resident on contact precautions. Findings include: WHIRLPOOL TUB Observation and interview on 11/29/23 at 10:44 a.m., with trained medication aid (TMA)-D who performed cleaning and disinfection the Master Care Aire Jet tub following completion of a resident bath. TMA-D reported she had completed her last bath for the day and would complete the cleaning and disinfection process. She then pointed to the instruction sheet posted on the side of the mirror…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to perform antibiotic stewardship to include antibiotic use protocols and a system to monitor antibiotic usage and determine if the prescribed antibiotics resolved the identified infectious process for 22 of 72 sampled residents (R2, R6, R7, R10, R11, R13, R21, R22, R28, R36, R37, R38, R43, R47, R53, R61, R167, R267, R268, R269, R270, and R271) identified in the facility's infection control surveillance. This had the potential to affect all 72 residents who were or may receive antibiotic therapy in the future. Findings include: Review of the September, October, and November 2023 infection control (IC) surveillance identified for the month of: 1). September 2023, 8 residents were receiving antibiotic treatment (R10, R13, R22, R167, R268, R269, R270 and R271). R167 was identified as receiving an antibiotic but there was no additional information included. There was no indication staff had re-assessed the resident's following completion of the therapy or notified their physicians to identify if symptoms had resolved or there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status and needs for 1 of 1 resident (R48) reviewed for elopement. Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated the resident had moderate cognitive impairment and had a Wander Guard elopement bracelet to be used daily. The MDS further indicated diagnoses of Alzheimer's disease. R48's face sheet printed 11/30/23, included diagnoses of dementia with Lewy bodies (abnormal deposits of a protein in the brain causing sleep, behavior, cognition, and movement disorders) and psychotic disorder with delusions and hallucinations. R48's care plan dated 5/25/22, indicated R48 had a problem for elopement and was at risk for elopement related to dementia and ability to ambulate independently. R28 was not at risk for elopement at that time, which was also dated 5/25/22 with status of active and frequency listed as PRN (as needed). R48's elopement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident cardiopulmonary Resuscitation(CPR) orders were consistent throughout the medical record for 1 of 16 residents reviewed (R3) and ensure staff were knowledgeable as to where to identify documents in order to prevent discrepancies. Findings include: R3's current, [DATE], physician orders identified on [DATE], an order for Do Not Resuscitate (DNR) was entered. R3's current, undated face sheet also reflected the DNR status. R3's current, undated care plan identified R3 was a DNR as of [DATE]. R3's current, Physician Orders for Life Sustaining Treatment (POLST) identified he was to receive CPR in an emergency. Interview on [DATE] at 3:57 p.m., with registered nurse (RN)-C, identified if R3's heart stopped she would start CPR because I know from memory, .he is a full code (CPR). RN-C reviewed chart and identified R3 is a DNR. RN-C then looked at the signed POLST and identified it said he was to have CPR. Interview on [DATE] at 4:15 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R16) received assistance with hand splints to prevent worsening of contractures. Findings include: R16's Diagnosis Report printed 11/29/23, included diagnosis of vascular dementia (problems in the blood supply to the brain leading to tissue death), and rheumatoid arthritis (chronic inflammatory disease that affects the joints). R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. The MDS further identified R16 required partial to moderate assist with transfers, and was dependent on staff for toileting and dressing. The MDS also included functional limitation of range of motion with impairment on one side upper extremities. R16's care plan dated 1/2/20, indicated R16 requires assistance with most of her activities of daily living and uses adaptive equipment. Interventions included R16 is to wear a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.