Wheatcrest Hills Healthcare Center

Based on observation, interview, and policy review the provider failed to ensure proper hand washing and glove use was followed during two of two observed meal services in the kitchen and dining room.Finding include: 1. Observation on 12/1/25 at 5:21 p.m. in the kitchen revealed: *Food and Nutrition Services (FANS) [NAME] I had gloves on, measured the temperature of the peas boiling on the stove, opened a sanitizer wipe and wiped off the thermometer. *He: -Threw the wipe away and removed his gloves. -Did not wash his hands. -Put on a new pair of gloves. -Measured the temperature of the pot roast at 174 degrees, put a pair of oven mitts over his gloves and moved the pot roast into the warming table. -Took off the oven mitts and opened the oven door with the same gloved hands he measured the temperature of the baked potatoes at 207 degrees. -Put another oven mitt over his left gloved hand and put the baked potatoes on the steam table. -Removed the oven mitt and then picked up the thermometer with the same gloves on and measured the temperature of the peas at 201 degrees. -Removed his…

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 certified nursing assistant (CNA)/certified medication aide (CMA) (M) and one of one licensed practical nurse (LPN) (D) performed hand hygiene with medication administration for five of five missed opportunities.*One of one LPN (D) wore a gown while she assessed a wound on a resident (36) who was on enhanced barrier precautions (EBP) (glove and gown use when providing contact care).Findings include: 1. Observation on 12/1/25 at 2:11 p.m. of resident 36's room revealed:*On the outside of resident 36's room door was a sign that indicated she was on EBP.*There were gowns in a hanging device behind resident 36's door.*In addition to the gowns in the hanging device there were shoes in some of the compartments.2. Interview on 12/1/25 at 2:11 p.m. with resident 10 revealed:*She was resident 36's roommate.*When resident 10 was asked if staff wore gowns when they provided her cares, she stated the gowns were for…

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 the safety and prevention for potential entrapment or injury for four of four sampled residents (1, 9, 15, and 27) who had side rails on their bed, and had documented alternatives attempted prior to the installation of side rails for two of two (1 and 15) sampled residents who were recently admitted .Findings include: 1. Observation on 12/1/25 at 2:50 p.m. of resident 9's room revealed: *She had a side rail on the left side of the head of her bed. *The side rail was upside down U-shaped and the opening within the side rail measured seven inches wide by 17 inches high. *The side rail was attached to a wooden board under the resident's air mattress and secured to the bed with a black strap. Observation and interview on 12/1/25 at 4:51 p.m. with resident 9 in her room revealed: *She used the side rail to reposition herself in bed and to help her sit up. *She had an air mattress on the bed, it was not secured and easily…

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 an ongoing restorative nursing program was completed according to residents' care planned needs for twelve of twelve sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) at risk for a decline in range of motion (ROM). Findings include: 1. Observation and interview on 6/17/25 at 10:41 a.m. with resident 1 and his wife revealed: *He had lived at the facility since January 2025. *He had received therapy services when he admitted , but his therapy program had ended. *His physician and therapist had mentioned to him that he would never walk again. *His restorative program was completed once a week and varied on which day of the week it occurred. *He expressed his desire to return home and that he would like his restorative program to be daily. *He had recently had a care conference on 6/11/25 during which he asked staff about adding more leg exercises to his restorative program. *Resident 1's wife stated she could…

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, observation, review of the facility reported incident (FRI) submitted to the South Dakota Department of Health (SD DOH), the provider failed to ensure four of four sampled residents (2, 26,32 and 34) had not been verbally berated or denied food by one of one certified food manager (CFM) D. Findings include: 1. Review of a grievance submitted on 2/22/24 revealed: *Resident 34 had asked the kitchen staff for a snack. *Dietary had informed her they would have snack in the afternoon and did not give her anything. Review of CFM D's response to the grievance revealed: *Around 11:00 a.m. resident 34 asked for the snack basket so she could look through it for munchies. *CFM D explained to her that the basket was filled and put out at 7:00 p.m. for the residents that got hungry between the hours of 7:00 p.m. and 6:00 a.m. *CFM D also explained that the nurse's station there should be some sandwiches if she was hungry. *Update with the resolution by CFM D revealed she: -Went to talk with resident 34 about snacks. -Explained that if she was wanting something…

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 provider failed to ensure that four of four sampled residents (3, 7, 32, and 43) had their call lights answered in a timely manner. Findings include: Observation and interview on 7/8/24 at 3:23 p.m. with resident 3 while she was seated in her wheelchair regarding call light wait time revealed: *She had been left on a commode for almost an hour. *That happened during the day shift. -That same thing happened again a few days later. Observation and interview on 7/8/24 at 3:48 p.m. with resident 32 while she was seated in her recliner regarding call light wait time revealed: *She had sat on the toilet for 45 minutes and waited to get help when she had pulled her call light. *Staff do not round on her at night. Interview on 7/9/24 at 2:21 p.m. with the director of nursing (DON) B regarding the call light system revealed: *If a resident were to pull down on the call light cord once it would sound once out at the nurse's station. *If a resident were to keep the cord pulled down it would make a constant buzzing sound at the nurse's station. *If 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, resident council meeting, and policy review the provider failed to offer nine of twelve sampled residents (2, 3, 7, 16, 19, 20, 22, 26 and 32) meal alternatives. Findings include: 1. Interview on 07/08/24 at 3:22 p.m. with resident 26 revealed: *Concerns about food had been brought to the resident council. *She stated The food is terrible. There have been a lot of problems. -Nothing happens, everyone is afraid to say anything to certified food manager [CFM D]. --The other day I didn't like the dinner. I don't eat fish, so I asked for a grilled cheese, and it was burned. I refused it and it was sent back to me like that, and I had to eat it or be hungry. I ate half. It was awful. 2. Interview on 07/08/24 at 4:11 p.m. with resident 2 revealed: *She recently had a choking episode and there were certain foods she could not eat. -Her son had to bring her food from home. --She had been unable to get a ham or turkey sandwich because they said they forgot to order it. ---The staff in the kitchen yelled at me for asking what Teriyaki beef was. I didn't think…

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 policy review the provider failed to ensure: *Proper glove use and hand hygiene were performed during two meal services by two of two dietary staff (dietary cook I and certified food manager D). *The food thermometer was sanitized appropriately during two meal services by three of four dietary staff (dietary cook I, certified food manager D, and dietary cook O). Findings include: 1.Observation and interview on 7/8/24 from 5:07 p.m. through 5:40 p.m. with dietary cook I and certified food manager (CFM) D revealed: *Dietary cook I: -Picked up a thermometer and took the temperature of a pot of white rice. -Set the thermometer on a cleaning rag. -Put on a pair of gloves without washing his hands. -Opened a drawer and took out a spoon and stirred a pot of beef tips. -Took that same thermometer from the rag and put it in the beef tips. -Wiped the thermometer off with that same rag. -Put that same thermometer in a pan of beets. -Wiped that thermometer off with that same rag and set it on the counter. -Took off his gloves and put on another pair of…

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 A. Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, and interview the provider failed to follow the individualized care plan that reflected the removal of dentures for one of one sampled resident (1), who required evaluation and treatment at the emergency department. provide care as directed in the care plans for the following: Findings include: 1. Review of the 3/2/24 SD DOH FRI involving resident 1 revealed: *He was observed making a whistling noise. *A small portion of his lower partial denture was visible in his mouth, and then was not visible. *The on-call provider was notified and orders were obtained to transfer him to the emergency department (ED) for evaluation. *The denture was removed in the ED and he returned to the facility. 2. Further review of the provider's FRI investigation and interview with certified nursing assistant (CNA) A revealed: *She had not removed resident 1's dentures that evening. *She stated she was aware his dentures should have…

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, observation, personnel file review, in-service and audit review, manufacturer's review, policy review, and job description review, the provider failed to ensure: *One of five sampled residents (6) was safely transferred according to manufacturer's instructions using a full-body mechanical lift by one of one certified nursing assistant (CNA) (D) that resulted in a bruise to the resident's right upper arm. *A device assessment for the proper mechanical lift to be used and documentation of the proper sling size were completed for one of five sampled residents (6) prior to the use of a full-body mechanical lift. Findings include: 1. Review of the 10/9/23 Facility Self-Reporting Form submitted to the South Dakota Department of Health (SD DOH) regarding resident 6 revealed: *The incident occurred on 10/9/23 at 6:00 a.m. and the final report included: -Resident 6 had osteoarthritis with chronic pain and was on comfort care related to a decline in her condition. --She had indicated 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 observation, interview, record review, and policy review, the provider failed to ensure a system was implemented for tracking and securing three government-controlled medications awaiting destruction that were expired or had been discontinued in one of one medication room. Findings include: Observation and interview on [DATE] at 9:10 a.m. of the medication room with registered nurse (RN) C revealed a medication storage machine. RN C stated: *The RX NOW machine was an automated emergency medication system. *Nurses used their fingerprints to obtain access to the RX NOW when they needed to remove emergency medications from it. *The RX NOW automatically documented who had accessed the system, when medications were removed, and what type of medication had been removed. Beside the RX NOW was a small opened plastic container. The lid could swing down to cover the contents in the box and had two holes that could have been used to place a zip tie to seal the lid. *Inside the open box were two small, sealed…

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.