Alcester Care And Rehab Center, Inc

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one sampled resident (1) who eloped (left the facility without staff knowledge) and was outside of the building approximately 18 minutes when a basement door was left unalarmed. Failure to ensure the alarm was activated may have contributed to his elopement. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 6/10/24 SD DOH FRI revealed: *On 6/9/24 at 3:13 p.m. the facility received a phone call from a community member alerting them that resident 1 was sitting outside the facility in the apartment parking lot close to the street. *Resident 1 was brought back to the facility by staff, was assessed, was not injured. The provider implemented systemic changes to ensure the deficient practice does not recur was confirmed after: record review revealed the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the provider failed to follow physician orders for one of one sampled resident (237). Findings include: 1. A review of resident 237's electronic medical record (EMR) revealed: *She had diagnoses of: -Generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities). -Paroxysmal anxiety (unpredictable recurrent attacks of severe anxiety). -Bipolar disorder, depressed, severe without psychotic features (mood swings ranging from depressive to manic high episodes). * She returned to the facility on 4/11/24 following a hospital stay with a physician's order for quetiapine (Seroquel) (a medication to stabilize mood) 25 milligrams (mg) one tablet by mouth three times daily as needed (PRN) for anxiety or agitation for 14 days. That order had ended on 4/25/24. *On 4/26/24 resident 237's physician extended that order for another 14 days. *There was no face-to-face visit completed by physician for the 4/26/24 order. *The order was faxed 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, record review, and policy review, the provider failed to ensure one of one sampled resident (1) had an updated care plan that reflected the following: *Interventions for missed dialysis treatments. *Current individualized care needs regarding activities of daily living and how to appropriately care for the resident. Findings include: 1. Observation and interview on 9/26/23 at 9:00 a.m. in resident 1's room with certified nursing assistant (CNA) D and another unidentified CNA indicated they were just finishing up care provided to the resident. The resident was lying in bed on his back. 2. Observation on 9/26/23 at 10:00 a.m. the resident was lying on his back in his bed. 3. Interview on 9/26/23 at 10:15 a.m. with LPN B nurse manager and LPN C regarding resident care plans revealed: *There were staffing concerns. *The updating of resident care plans were not completed. *Many of the management staff had to work on the floor due to staff shortages. 4. Interview on 9/26/23 at 10:30 a.m. with administrator A revealed the MDS (Minimum Data Set) coordinator…

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 record review, interview, and policy review, the provider failed to ensure one of one sampled resident (1) who had a witnessed fall had the following completed: *A thorough head to toe assessment completed by the nurse at the time of the fall. *A fall assessment. *Vital signs obtained every shift for 72 hours after the fall. *Physician and family notification of the fall. *An update to the care plan to include new interventions to prevent another fall. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *He had a witnessed fall on 8/23/23 at 3:55 a.m. -The resident had called to use the restroom; the registered nurse (RN) on the night shift was assisting him. -The resident was using his walker and there was a gait belt used by the RN. -The resident was having difficulty turning himself and the residents legs had become tired. -The nurse lowered the resident to the floor. -There were no injuries documented. -The staff transferred the resident back to his bed with a Hoyer lift. *On 8/25/23 at 11:36 p.m. were the only set of vital signs 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (1) who required dialysis three times a week at an off-site contracted end stage renal disease facility: *Had the appropriate transportation arrangements set up to ensure dialysis was completed as ordered by the physician. *Had ongoing assessments and monitoring of the residents condition for complications related to missed dialysis treatments. *Physician was notified of the missed dialysis treatments. 1. Observation and interview on 9/26/23 at 9:00 a.m. with resident 1 in his room revealed: *He was lying in bed on his back. *The CNA D and an unidentified CNA had just performed peri care due to a bowel movement. *There was a 16 ounce can of beer with a straw, a can of soda with a straw, and a clear plastic mug of water that was on his bedside table. *He stated he would drink two cans of beer a day, and soda pop. *He was aware of the date and his whereabouts but was slow to answer. *When…

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 staff schedule review the provider failed to ensure a registered nurse (RN) had been scheduled for eight hours of coverage for two of four weekends in February 2023. Findings include: 1. Interview and staff schedule review on 3/9/23 at 11:00 a.m. with director of nursing (DON) B revealed she: *Had worked full time Monday through Friday completing Minimum Data Set (MDS). *Was available to staff by phone twenty-fours hours per day seven days per week. 2. Interview and staff schedule review on 3/09/23 at 12:43 p.m. with administrator A regarding RN coverage revealed: *She had been aware that they did not have eight hours per day of RN coverage seven days per week. *She was attempting to hire an RN.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and policy review, the provider failed to ensure appropriate disinfection after resident use for of one of one whirlpool and furnishings in the one of one tub room by one of one certified nursing assistant (CNA) E. Findings include: 1. Observations on 3/7/23 at 11:19 a.m. and 3:59 p.m. of the whirlpool room revealed: *The door to the room was open. A sign on the door stated to keep the door locked. *A stack of towels was setting on top of a short gray plastic storage cabinet against the right wall inside the room. The towels were out in the open and uncovered. *A reception-style chair was positioned against the right wall beside the storage cabinet with towels laid out on the seating surface of the chair. The towels were flattened in the center and appeared as if someone had been sitting on them. *Water was pooled on the floor in the center of the room and around the whirlpool located on the left side of the room. *The safety strap on the whirlpool lift chair was lying in the…

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, record review, and policy review the provider failed to ensure one of one sampled resident's (4) advanced directives had been followed. Findings include: Record review of resident 4's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Past medical history included: -Atrial fibrillation *Her code status was do not resuscitate (DNR) {do not perform cardiopulmonary resuscitation}. -Had not been updated to indicate DNH (do not hospitalize) and DNI (do not intubate) {inserting a breathing tube}. *On10/1/22: - At 11:25 a.m. and unidentified CNA had notified licensed practical nurse (LPN) G that the resident was not acting right, her skin was clammy and hot to the touch, her checks were flushed, and had labored breathing. - At 11:26 a.m. resident 4 was assessed by LPN G and the assessment revealed: -Blood pressure of 106/62 (normal blood pressure is 120/80). -Temperature of 98.7 (normal temperature is 98.6) -Respiratory rate of 24 respirations per minute (normal respiratory rate…

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 record review, observation, interview, and policy review the provider failed to ensure oxygen tubing had been changed per facility policy every two weeks for one of three samples residents (12). Findings include: 1. Review of resident 12's medical record revealed: *The resident had diagnosis of: -Chronic obstructive pulmonary disease (COPD) with (acute) exacerbation. -Chronic diastolic (congestive) heart failure. -Chronic kidney disease, stage 3 unspecified. *She used oxygen to keep saturation above 90% (normal oxygen saturations are 90%-100%). *She had a physician's order to replace and date humidifier on the oxygen concentrator monthly at bedtime. *She had recent hospitalization for acute COPD exacerbation. Observation and interview on 3/8/23 at 8:53 a.m. of resident 12 in her room revealed: *She was sitting in her recliner watching television. *She was using a nasal canula for oxygen. *An oxygen concentrator was located next to her bed set at two liters. *She was not sure when the tubing had been changed. *The oxygen tubing had tape wrapped around it that was dated 2/6.…

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, record review, interview, and policy review the provider failed to ensure safety assessments had been completed and documented for three of eight sampled residents (8, 20, and 23) who had half side rails attached onto their beds. Findings include: 1. Observation on 3/7/23 at 11:50 a.m. of resident 20's room revealed he had one half side rail on the left side of his bed. Review of resident 20's medical record revealed: *He had been admitted on [DATE]. *His 10/4/22 Brief Interview of Mental Status (BIMS) revealed no cognitive impairment. *His last revised care plan was dated 1/18/23 revealed he used one-half side rail to encourage independence with turning and re-positioning in his bed. *There had been no documentation that a side rail safety assessment for his one-half side rail had been completed. 2. Observation on 3/7/23 at 12:44 p.m. of resident 8's room revealed she had bilateral half side rails on her bed. Review of resident 8's medical record revealed: *She had been admitted on [DATE].…

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.