Michael J Fitzmaurice South Dakota Veterans Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *Hand hygiene and personal protective equipment (PPE) use by four of four observed staff (E, O, R, and S) for one sampled resident (360) with a physician order for contact precautions related to an infected unhealed chest wound and two sampled residents (10 and 49) on enhanced barrier precautions (EBP) who resided in the NASA unit. *The storage and maintenance of wound care supplies in one of one observed treatment cart located in the NASA unit. Findings include: 1. A review of resident 360's electronic medical record (EMR) revealed: *He was admitted on [DATE] and resided in the NASA unit. *He had a diagnosis of chronic kidney disease, stage 5, which required dialysis (a process that filters waste and excess fluids from the blood when the kidneys are unable to do so effectively) three times a week. *He had a recent dialysis fistula (a connection made between…

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 an environment free from potential hazards by not following their policy and ensuring that lighters for two of two sampled residents (33 and 42) who smoked were secured at the nurses' station when not in use. Findings include: 1. Observation on 4/29/25 of resident 33 in the dining room at 4:43 p.m.: *Resident 33 asked homemaker K for cigarettes. *Homemaker K provided her with two cigarettes but no lighter. *Multiple random daily observations from 4/29/25 through 5/1/25 revealed resident 33 was outside of the unit at the designated smoking area. *Observation on 5/1/25 at 2:30 p.m. of resident 33 in her neighborhood revealed she: *Was wearing a coat and asked another resident to go out to the smoking area with her. *Received two cigarettes from an unidentified staff member. *Had not requested or received a lighter from staff prior to exiting the unit and going outside to the smoking area. *Interview on 4/29/25 at 4:45 p.m. with resident 33 revealed: *She was going outside to smoke. *She…

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 assess bed rails for safe use for five of five sampled residents (24, 28, 41, 44, and 47) who had bed rails on their beds. Findings included: 1. Observation on 4/29/25 at 9:57 a.m. of resident 28's room revealed grab bars were on both sides of the bed. Review of resident 28's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *A device evaluation for his use of bed rails was last completed on 1/13/25. -He utilized the bed rails for turning and repositioning while in bed. There was no documentation that an assessment of the bed rails had been completed to determine safe use or measurements of the bed rails for risk of entrapment and injury. 2. Observation and interview on 4/29/25 at 10:00 a.m. with resident 24 in his room revealed: *He had bed rails on both sides of his bed. *He was unsure why he had the bed rails, and stated they had come with the bed when he was admitted to the facility. Review 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.

Based on observation, record review, interview, and policy review, the provider failed to ensure the care plan was reviewed and revised to reflect the current necessary care needs for one of one sampled resident (47). Findings include: 1. Observation on 4/29/25 at 11:35 a.m. of resident 47 in his room revealed: *He was seated in a recliner with the footrest halfway up. -He had on a pair of gripper socks on his feet. Observation on 4/30/25 at 1:48 p.m. of resident 47 in his room revealed: *He was seated in a recliner with the footrest up, and he was covered with a blanket. *A wheelchair was across the room, against the wall, with a pair of protective boots on the seat. Observation on 4/30/25 at 2:59 p.m. and again at 3:07 p.m. of resident 47 revealed he was lying on his bed, his eyes were closed, and a bed cradle device (suspends bedsheets and blankets off a person's legs and feet) was holding the blankets off his feet. Review of resident 47's electronic medical record (EMR) revealed: *His admission date was 1/16/24. *His Brief Interview of Mental Status assessment score was a 3,…

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 the paper copy of the standardized protocol for stage II pressure ulcer interventions was followed according to policy for one of two sampled residents (27) with a stage II facility acquired pressure ulcer (a skin injury incurred while residing at the facility). *Implement the use of a pressure-reducing device to mitigate the risk for one of two sampled residents (27) who developed a stage II facility acquired pressure ulcer. Findings include: 1. Observations on 2/13/24 at 11:00 a.m. and again at 12:05 p.m. of resident 27 revealed he: *Participated in group exercise seated in his wheelchair. *Ate lunch in the main dining room seated in his wheelchair. -There was a pressure reducing cushion on the seat of his wheelchair. Review of resident 27's electronic medical record (EMR) revealed a 2/8/24 nurse progress note: *An open area to the resident's right buttock was identified. *It was a one centimeter (cm) by one cm…

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 infection prevention and control practices were implemented for the following: *Effective whirlpool (WP) tub cleaning by one of one certified homemaker (J) in one of five multi-use resident WP tub rooms after bathing one of one sampled resident (8). *Appropriate mask, face shield, and gown use by one of one licensed practical nurse (LPN) (I) during care for one of four sampled residents (34) on transmission-based precautions (TBP). *Appropriate face shield and mask use by one of one certified homemaker (L) during care for one of four residents (52) on TBP. *Appropriate hand hygiene, glove use, and dressing application by one of one LPN (I) during a dressing change for one of two sampled residents (27). Findings include: 1. Observation and interview on 2/13/24 at 10:00 a.m. with certified homemaker J in the WP tub room revealed: *She used the following process to clean the WP tub after bathing resident 8: -While the WP tub filled with water she pressed the disinfectant button on 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.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *The psychosocial well-being and dignity was maintained for one of four sampled residents (46) during three of three observed meal services. *Privacy for one of two sampled residents (29) was provided during his Foley catheter care. Findings include: 1. Random observations on 2/13/24 between 9:45 a.m. and 12:06 p.m. with resident 46 revealed: *He sat alone facing an empty kitchenette. -His Broda chair (a specialty wheelchair that provided supportive positioning and repositioning ability) was pushed against the kitchenette countertop with the wheels of the chair locked. -His back faced the main dining room. *A quilt with sensory touch items secured to it was placed on the countertop in front of him. -He occasionally grazed the items on that quilt with his fingers. *Other times he was asleep, mumbling, repetitively moving his trunk forward then back or reaching for seasonal decorations just out of his reach. -When staff walked past the resident they briefly spoke to him, offered him…

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 identify one of four sampled residents (46) seated in a wheelchair was restrained with locked brakes pushed against a countertop. Findings include: 1. Random observations on 2/13/24 between 9:45 a.m. and 12:06 p.m. with resident 46 revealed: *He sat alone facing an empty kitchenette. -His Broda chair (a specialty wheelchair that provided supportive positioning and repositioning ability) was pushed against the kitchenette countertop and his wheels were locked. -There was no lap belt in the chair. *A quilt with sensory touch items secured to it was placed on the countertop in front of him. -He occasionally grazed the items on that quilt with his fingers. *Other times he was asleep, mumbling, repetitively moving his trunk forward then back or reaching for seasonal decorations just out of his reach. -When staff walked past the resident they briefly spoke to him, offered him fluids or moved things out of his reach. Random…

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 four residents (46) at risk for skin breakdown was repositioned according to the protocol of the facility. *One of four sampled residents (46) received proper and timely peri-care following a bowel movement. Findings include: 1. Random observations on 2/13/24 between 9:45 a.m. and 12:06 p.m. with resident 46 revealed he: *Sat in a Broda chair (a specialty wheelchair that provided supportive positioning and repositioning ability) at a countertop facing a kitchenette. -The brakes on that chair were locked. *A quilt with sensory touch items secured to it was placed on the countertop in front of him. -He occasionally grazed the items on that quilt with his fingers. *Other times he was asleep, mumbling, repetitively moving his trunk forward then back or reaching for seasonal decorations just out of his reach. -When staff walked past the resident they briefly spoke to him, offered him fluids or would move things out of his reach. Interview on 2/14/24 at 8:55 a.m. with doctor 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 Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (57) with a physician ordered renal dialysis diet was implemented. Findings include: 1. Observation and interview on 2/13/24 at 2:57 p.m. with resident 57 revealed he: *Appeared tired, was yawning, and stated he had just returned from renal dialysis. *Had been a resident at the nursing facility for about a month and resided on the [NAME] hallway. -Had been a resident of the independent living part of the facility but was hospitalized due to a spike in his potassium levels and was transferred back from the hospital into the nursing facility. *Had been receiving renal dialysis for about four years. *Was supposed to be receiving a renal diet, but had not received a renal diet since he was admitted . -Stated, Yesterday I had a grilled cheese and potato soup. That was what they served me. They are both high in phosphorus. *Felt his diet was very important and would have preferred a renal diet.…

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 Observation and interview on 2/14/23 at 12:20 p.m. in Stars and Stripes satellite kitchen with dietary aide E revealed: *He had on a pair of single-use gloves on both hands. *While wearing those gloves he: -Opened a drawer and took a serving utensil out. -He then removed plastic wrap from a ready-to-eat sandwich and using his potentially contaminated glove he placed the sandwich on a plate. -He then served the noon meal with those same gloved hands. --While wearing the same gloves he touched multiple potentially contaminated items including drawer handles, counter tops and then picked up garlic toast with those potentially contaminated gloves six different times. Interview with dietary aide E revealed he: *Always wore gloves while serving the resident meals. -He did not change gloves or complete hand hygiene while serving resident meals. *Thought he could touch the garlic toast with his gloved hands because they were gloved. -He agreed the garlic toast was a ready-to-eat food. *He agreed he had touched multiple…

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 (13) who had an injury of unknown origin was investigated and reported to the South Dakota Department of Health (SDDOH). Findings include: Observation and interview on 2/14/23 at 1:20 p.m. with resident 13 revealed: *He was awake and sitting in his wheelchair watching television. *The inside corner of his right eye, from just below his eyebrow and extending to below the lower lid of his eye appeared to be black and blue. -He was unaware what happened to his eye. Review of resident 13's electronic medical record revealed his: *Diagnoses included: heart failure, anemia, macular degeneration, and chronic obstructive pulmonary disease. *Medications included Eliquis, which was a blood thinner. *Care plan included he: -Had poor eyesight. -Had short term memory loss. -Had the potential to fall down. -Needed assistance from one or two staff members for most of his cares. *Nursing progress notes included that on 2/12/22 he had a New bruise to his R [right] inner eye…

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's (46) physician orders had been clarified and were followed. Findings include: Observation and interview 2/14/23 at 9:54 a.m. with resident 46 in his room revealed: *He was sitting in his wheelchair. *His feet were swollen. *He had been arguing with an unidentified nurse regarding how his compression socks were to have been put on his legs and feet. -The nurse had stated the tan-colored compression stocking should have been put on before the black stocking. Review of resident 46's medical record revealed: *His diagnoses included: diabetes, peripheral vascular disease, congestive heart failure, and edema *His treatment administration records (TAR) were documented on a paper form. *His physician orders on this form included: -On 12/31/21 an order for Circaid stockings to bilateral lower extremities daily on in a.m. and off in p.m. for edema and improved circulation -On 5/26/22 an order 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.