Avantara Norton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of two of two sampled residents (2 and 3) who eloped (left the facility without staff knowledge) from the front door of the facility on 7/26/25 and 9/12/25. Both residents had been mistaken for visitors at the time of their elopements. The facility's front door alarm system had been bypassed during the elopements by using an employee's badge. Findings include:1. Review of the provider's 7/26/25 SD DOH FRI involving resident 2 revealed:*On 7/26/25 at approximately 1:47 p.m., certified nursing assistant E returned to the facility after being on break and noticed resident 2 sitting outside in his wheelchair on the sidewalk near the entrance by himself.*According to the provider's investigation, the resident left the facility at approximately 1:27 p.m. when a visitor had opened the front door.*Resident 2's goal was to go outside and enjoy the sun…

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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, policy review, observation, interview, and record review, the provider failed to ensure that one of one employee (cook J) served food at a safe temperature, according to the provider's policy, which potentially led to one of one resident (4) having skin redness after spilling soup on himself. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incident.Findings include:1. Review of the provider's 12/19/25 FRI revealed that at about 7:30 p.m. on 12/19/25, resident 4 was eating tomato soup in his room. The soup was 180 degrees Fahrenheit on the steam table line in the kitchen as it was plated. When resident 4 was about finished with his soup, he accidentally spilled the soup on the left upper quadrant of his chest and his left upper arm. He alerted nursing staff and reported no pain at that time.His skin was assessed and noted light…

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 staff members followed infection prevention practices for:*Personal protective equipment (PPE) use by one of one observed certified nursing assistant (CNA) D when providing care for five of five sampled residents (1, 2, 3, 4, and 5) on enhanced barrier precautions (use of gown and gloves while providing contact care)(EBP).*Cleaning shared-use equipment, specifically lift devices, after each resident's use by one of one CNA D.*Maintaining a clean environment in one of one sampled resident (6) room who reported spilled urine that remained on the floor for about two hours. Findings include: 1. Observation on 11/13/25 at 7:08 a.m. of certified nursing assistant (CNA) D revealed she brought a resident lift (a mechanical device used to transfer residents) out of resident 7's room, did not clean the lift, and placed it in the hallway after use. 2. Observation on 11/23/25 at 7:42 a.m. of CNA D revealed:*She entered resident 1's room with the same lift and transferred the resident from his bed to his wheelchair…

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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, review of call light log, review of personnel file, interviews and policy review, the provider failed to protect the resident's right to be free from neglect for one of one sampled resident (2) who waited for staff assistance for more than an hour after turning on his call light. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.Findings include: 1. Review of the provider's 5/30/25 SD DOH FRI regarding resident 2 revealed:*Resident 2 filed a grievance with the provider on 5/30/25.*On the night of 5/28/25 resident 2 did not receive help from staff. -His call light (a device that alerts staff of a request for assistance) had been on for an extended period.-Certified nursing assistant (CNA) D came in to his room to assist him, was rude, and walked out.-CNA D was suspended pending investigation.-The resident's primary care provider (PCP) was notified of the grievance.-An investigation was…

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 South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure professional nursing standards of practice regarding medication administration were followed by licensed practical nurse (LPN) (F) who administered one of one sampled resident'(4) another resident's medications. That failure resulted in medication errors.Findings include:1. Review of the 6/9/25 SD DOH FRI revealed:* On the evening of 6/9/25, LPN F mistakenly administered resident 5's medications to resident 4.*Medications administered to resident 4 included Zolpidem (medication to assist with sleeping) 10 milligrams (mg) and Eliquis (blood thinning medication) 5 mg.*Resident 4 had an allergy to Zolpidem and did not take blood thinning medications.*The on-call physician was notified of those medication errors.*The on-call physician ordered for the resident to be monitored by staff and for resident 4's normal medications to be resumed the next day.*No adverse reactions were noted to resident 4 due to the medication errors. 2.…

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 South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview and policy review, the provider failed to protect the safety of one of one sampled resident (1) identified as at risk for elopement (leaving the facility without staff knowledge). Who was assisted out of the building by certified nursing assistant (CNA) H who left the facility property and resident 1 remained outside unsupervised. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.Findings include:1.Review of the provider's 6/7/25 SD DOH FRI involving resident 1 revealed:*On 6/7/25 at 6:31 p.m. resident 1 exited the building when certified nursing assistant (CNA) H held the door open for her at the end of her shift.*Resident 1 remained on the property in the front of the building unsupervised.*CNA P and licensed practical nurse (LPN) I recognized when leaving resident 1 should not have been outside alone at…

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 record review, interview, and policy review, the provider failed to follow professional standards by not having ensured two of two sampled residents (1 and 2) had received their PRN (as needed) controlled (medications with risk for abuse and addiction) pain medications as ordered by the physician. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed his medication administration record (MAR) indicated: *He had a physician's order for oxycodone (a controlled pain medication), 5 milligram (mg) tablet, Give 2 tablet[s] orally every 4 hours as needed for pain. *On 2/17/25, he was given two oxycodone tablets by registered nurse (RN) E at 1:16 a.m., and two oxycodone tablets by licensed practical nurse (LPN) G at 2:12 a.m. -Less than one hour had passed between those administrations. *On 3/20/25, he was given one oxycodone tablet by certified medication aide (CMA) F at 4:37 p.m., and two oxycodone tablets by LPN H at 7:35 p.m. -Less than three hours had passed between those…

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 the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure two of two sampled residents' (1 and 2) prescribed controlled (medications with risk for abuse and addiction) pain medications were not diverted (when prescribed medication is obtained or used illegally by another person) by one registered nurse (RN) (E). Failure to ensure prevention of diversion of those medications had the potential to cause those residents increased pain and potentially placed all residents' safety at risk who were under RN E's care. This citation is considered past non-compliance based on the provider's identification of the potential diversion and actions implemented following the incident. Findings include: 1. Review of the provider's 3/3/25 SD DOH FRI revealed: *Director of nursing (DON) B notified registered nurse (RN) E's Health Professional Assistance Program (HPAP) caseworker regarding concerns that RN E may have been diverting controlled medications from the facility due to his agitated…

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 South Dakota Department of Health (SD DOH) complaint report, record review, interview, and policy review, the provider failed to ensure one of one sampled resident (3) had received discharge instructions and education on the risks versus benefits prior to leaving against medical advice (AMA). Findings include: 1. Review of the SD DOH complaint intake report received on 4/9/25 revealed: *A resident had been admitted to the facility on [DATE]. *There were concerns of the resident being unhappy with her medication administration and the lack of explanation of her medication that had been administered. 2. Review of resident 3's electronic medical record (EMR) revealed: *She was admitted on [DATE] for rehabilitation services following a left hip replacement. *Three days later she left AMA. *She had signed the provider's AMA form prior to leaving. *A Brief Interview for Mental Status (a tool to determine cognitive function) was not completed prior to her leaving AMA to support if she had been competent enough…

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 and interview, the provider failed to ensure the proper Medicare notices were filled out completely and were in the required format for three of three sampled residents (12, 13, and 354) prior to their discharge from Medicare Part A skilled services. Findings include: 1. Review of the three Entrance Conference Worksheets completed by the provider on 2/25/25 revealed 50 residents were identified as having been discharged from Medicare Part A skilled services: *Twenty-five of those residents remained in the facility following their discharge from Medicare Part A skilled services. *Twenty-five of those residents were discharged to home or to a lesser care level following their discharge from Medicare Part A skilled services. 2. Review of resident 354's CMS (Centers for Medicare and Medicaid Services) SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by Minimum Data Set (MDS) coordinator H on 2/26/25 revealed: *Resident 354's Medicare Part A Skilled Services Episode start date was 9/25/24. *Her last covered day on Medicare…

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 proper infection control practices had been followed for six of six sampled residents (6,12,22,32,54, and 62) who required respirator devices had appropriate cleaning, storage, and replacement of those devices. 1. Observation and interview on 2/25/25 at 6:49 a.m. with resident 54 in his room revealed: *There was an oxygen concentrator at his bedside. *There was a continuous positive airway pressure (CPAP) machine (a machine to treat sleep-related breathing issues) on his bedside table. *He had lived in the facility for about three weeks. *He indicated he wore the oxygen as needed. *He stated he was supposed to wear the CPAP every night, but he had only been using it intermittently at night. *He was admitted to the facility with oxygen and the CPAP. Observation on 2/26/25 at 11:14 a.m. of resident 54's room revealed: *The room door was open but resident 54 was not in his room. *The oxygen nasal cannula (tubing 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 observation, interview, record review, and policy review, the provider failed to follow acceptable food standards and their policies to ensure refrigerator temperatures were properly maintained and documented for safe food temperatures, food was labeled, stored, and monitored for safe consumption and to prevent potential outbreaks of foodborne illness for thirteen of thirteen observed residents' (1, 6, 18, 19, 22, 36, 37, 44, 49, 50, 63, 65, and 79) personal refrigerators. Findings include: 1. Observation on 2/25/25 from 9:15 a.m. through 12:50 p.m. of residents' personal refrigerators and review of temperature logs revealed: *The temperature logs did not indicate: -The temperature should have been in a certain range (i.e. 41° Fahrenheit (F) or lower). -What should have been done if the temperature was out of an acceptable range or higher than 41° F. *Resident 1's refrigerator was missing temperature documentation for 2/1/25, 2/2/25, 2/7/25, 2/8/25, 2/9/25, 2/15/25, 2/16/25, 2/20/25, and 2/24/25. *There was no thermometer in the refrigerator. *Resident 1 had documented…

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 facility was operated and administered by administrator A, director of nursing (DON) B, assistant director of nursing (ADON) C, and unit managers F and G, in a manner that ensured quality of life and overall well-being for all 94 residents in the facility. Findings include: 1. Observations, interviews, record reviews, and policy reviews throughout the survey on 2/25/25 through 2/27/25 and 3/4/25 through 3/5/25 revealed administrator A, DON B, ADON C, and unit managers F and G, had not ensured the quality of life and overall well-being of all the residents who lived in the facility. This was evidenced by: *A widespread system breakdown to ensure infection control practices, policies and procedures were followed regarding: -Enhanced barrier precautions. -Personal protective equipment. -Air-borne vs. droplet precautions as it pertained to Covid. -Hand hygiene. -Oxygen concentrator preventive maintenance. *The development and revision of care plans in a timely manner. *Services provided…

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 observations, interview, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the overall quality of life and well-being for all 94 residents in the facility. Findings include: 1. During the survey from 2/25/25 through 2/27/25 and 3/4/25 through 3/5/25 deficient practices identified the provider had not been operating in a manner to ensure the residents had received quality care. Refer to F582, F656, F658, F675, F695, F812, F835, and F880.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure proper infection control practices had been followed for: *Two of two sampled residents (5 and 70) who had wound dressings changed by two of two observed staff licensed practical nurse/wound nurse (LPN) M and certified nurse practitioner (CNP) CC. *Four of four sampled residents (29,34, 345, and 350) who required Enhanced Barrier Precautions (EBP) (an infection control strategy in nursing homes that expands the use of personal protective equipment (PPE) specifically gowns and gloves, during high contact resident care activities to reduce the transmission of multi-drug-resistant organisms (MDROs). *Four of four sampled residents (5, 6, 35, 37, and 64) who had unlabeled personal care products to identify the correct resident for usages. Findings include: 1. Observation on [DATE] at 9:13 a.m. with LPN/wound nurse M and CNP CC while they performed a dressing change for resident 70's abdominal wound revealed: *Dressing supplies had been…

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 resident care plans reflected the current individualized needs for: *One of one sampled resident (54) who utilized oxygen and a respiratory device. *One of one sampled resident (64) who had his indwelling feeding tube removed. 1. Observation and interview on 2/25/25 at 6:49 a.m. with resident 54 revealed: *An oxygen concentrator (a machine that takes surrounding air and purifies it into breathable oxygen) was at his bedside. *A continuous positive airway pressure (CPAP) machine (a machine to treat sleep-related breathing issues) was on his bedside table. *He had lived in the facility for about three weeks. *He indicated he wore the oxygen as needed. *He stated he was supposed to wear the CPAP every night, but he had only been using it intermittently at night. *He was admitted to the facility with the oxygen and CPAP. Review of resident 54's EMR revealed: *He was admitted on [DATE]. *His 2/2/25 BIMS assessment score…

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 follow professional standards for medication administration and physician notification regarding the: *Administration of prescribed medication within the scheduled timeframe for one of one sampled resident (349). *Prompt physician notification of one of one sampled resident's (349) significant weight gain. *Prompt physician notification of abnormal vital signs (such as heart rate and blood pressure) and the holding of medications for one of one sampled resident (51). Findings include: 1. Observation and interview on 2/25/25 at 2:11 p.m. with resident 349 and his spouse in his room revealed: *He was sitting in his recliner with his feet elevated. *He had significant swelling in his lower legs. *They both stated they had concerns about resident 349 getting his Parkinson's medication on time. *Resident 349 stated there was one day when he had to ask staff three times for his dose of his Parkinson's medication. *His wife stated…

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 the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review the provider failed to establish and ensure ongoing open communication with the hospice services provider regarding the use of an overlay air mattress (an air-filled mattress placed over a regular non-air mattress) that had been used by one of one sample resident (1). Findings include: 1.Review of the provider's 12/20/24 SD DOH FRI revealed: *On 12/13/24 [name] wound nurse asked [name] administrator about [name] resident [1] having an overlay air mattress on her bed versus having an alternating low air loss mattress (a type of mattress that combines low air loss and alternating pressure to help prevent and treat pressure ulcers) in her room. *Per quality assurance (QA) team it is facility preference to utilize alternating low air loss mattress. *[name] wound nurse visited with [name] resident regarding the alternating low air loss mattress versus an overlay air mattress. [name]…

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 South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to protect one of one sampled resident (1) from neglect by certified nursing assistant (CNA) (C) who did not provide timely care, which potentially resulted in the resident being incontinent for an unknown length of time and may have contributed to the resident's development of two skin sores. Findings include: 1. Review of the provider's SD DOH FRI submitted on 10/26/24 at 4:23 p.m. revealed: *CNA C worked in the wing where resident 1 resided during the night shift of 10/25/24. *CNA C had asked CNA D to assist her with her assigned residents, and she had assumed resident 1's care needs had been provided by CNA D. *CNA C did not verify resident 1's care had been provided. *CNA D stated she did help on CNA C's wing, but did not help with resident 1. *Camera footage for the time period was reviewed and revealed that resident 1 was checked on at 10:00 p.m. by CNA F and was not checked on again until approximately 4:30 a.m. on 10/26/24 by licensed…

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 South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, and policy review the provider failed to ensure the care plan reflected the current individualized treatment needs for a tunneled chest catheter (a thin tube inserted into a vein in the chest, neck, or groin and tunneled under the skin to a large vein near the heart referred to as a central venous catheter (CVC) to allow access to the vein for medication administration) versus a peripherally inserted central catheter (PICC) inserted into a vein in the upper arm for one of one sampled resident (1). Findings include: 1. Review of resident 1's electronic medical record revealed: *Multiple references of the tunneled chest catheter as referred to as a PICC line multiple times by the resident's clinical nurse practitioner (CNP) and the nursing home staff. *A health status note dated 10/11/24, that indicated resident 1 had a tunneled chest catheter placed on 10/10/24 on the right side of her chest in the hospital. *Resident 1 would be returning to the facility and was to receive intravenous…

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 the South Dakota Department of Health (SD DOH) complaint online report, observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (1) had a baseline care plan created that identified her care needs, goals, and interventions within 48 hours of admission. Findings include: 1. Review of SD DOH complaint online report revealed: *Resident 1 was admitted to the facility on [DATE]. *The complainant reported that resident 1 experienced excruciating pain throughout the entire weekend following her admission. *It was also reported that the resident's room was not cleaned. *The complainant reported that resident 1 should have had dressing changes to her legs multiple times per day. -The complainant reported that dressings changes were not completed, and drainage from resident 1's leg wounds would collect on the floor. 2. Observation throughout the facility on 9/25/24 revealed: *Resident rooms appeared to be clean and uncluttered. *Trash cans were…

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.

A. Based on South Dakota Department of Health (SD DOH) complaint online report, observation, interview, and policy review, the provider failed to administer medications ordered by the physician for 2 of 2 sampled residents (1 and 2). Findings include: 1. Review of SD DOH 8/14/24 complaint revealed: *Resident 2 had a lung transplant and had not been getting her immunosuppressant medication. *The medication had not been ordered timely and received at the facility. 2.Interview on 8/20/24 at 10:17 a.m. with registered nurse (RN) unit manager O regarding missed doses of resident 2's medication Everolimus (an immunosuppressant medication for her lung transplant) revealed: *He was aware that she had not received a dose on 8/18/24. *Her 2.5 mg tablet supply of Everolimus did not come in. * He notified director of nursing (DON) B and he had emailed the pharmacy and expected it to be delivered today 8/20/24. *He agreed the doctor should have been notified. 3. Interview on 8/20/24 at 12:38 p.m. with resident 2 revealed: *She had a lung transplant on March 20, 2023. *She stated her medications…

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 South Dakota Department of Health (SD DOH) complaint online report, observation, interview, resident council meeting minutes review, and policy review the provider failed to ensure room trays were served at a satisfactory temperature for two of three sampled residents (4 and 6). Findings include: 1. Review of the 8/2/24 DOH complaint online report revealed: *Alternate menu items were: -Warmed up. -Wrapped in plastic. -Set on the counter until served. *The food had sat on the counter for an hour before being served. *Hamburgers, chicken strips, and fried eggs were examples of foods left on the counter. 2. Observation and interview on 8/19/24 at 4:30 p.m. with resident 4 in his room regarding food temperatures revealed: *He was sitting up in his bed. *He preferred to eat in his room. *Breakfast was the only meal he ate. *His menu consisted of two fried eggs and a hamburger patty. *His breakfast had been delivered to his room cold several times. *He had discussed his issue with the food temperature with the dietary manager. Observation and interview with cook U on 8/20/24 from…

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 maintain a clean and sanitary foodservice environment on one of one kitchen and two of two kitchenettes and implement safe food storage practices in one of one kitchen. Findings include: 1. Observation and interview on 7/16/24 from 3:31 p.m. to 3:45 p.m. in the main kitchen with dietary manager (DM) B revealed: *The overhead ventilation hood panels above the convection oven and clean dishes storage shelves were covered in a layer of grease and dust. *There was a pungent smell coming from the dirty dish room. *In the dirty dish room: -There was dried food splattered extensively on the ceiling. -Fruit flies were flying throughout the kitchen. There was a large collection of them around the trash cans. -The sink leading into the dishwasher was leaking. -DM B claimed the sink was leaking because it was full of water and dirty dishes, and that it had not been leaking for that long. -There was standing water on the floor beneath…

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 South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to immediately report allegations of abuse experienced by one of one sampled resident (1). Failure to immediately report allegations of abuse delayed the reporting and investigation process, potentially putting residents at risk for further alleged abuse. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the SD DOH FRI submitted on 5/28/24 at 11:22 a.m. revealed: *A written grievance form was reviewed by the administrator on 5/28/24. *Resident 1 reported that certified nurse aide (CNA) E was rough with her on the morning of 5/27/24. *She reported that CNA E forced her to wake up at 7:10AM and demanded she take a shower because she urinated on herself, and grabbed her by the arms and pushed her down into the chair. 2. Interview on 6/20/24 at 12:29 a.m. with administrator A and DON B regarding the incident 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.

Substantial compliance was confirmed on 4/14/24 at 3:23 p.m. after a phone interview was conducted with hospice liaison that the numbers for three of the nurse's stations were provided to the hospice provider for faxing physician's orders that would include new medication orders.

Based on observation, interview, record review, and policy review, the provider failed to ensure medications were administered at the time they were prepared and by the individual who prepared the medications for one of one sampled resident (4). Findings include: 1. Observation and interview on 3/12/24 at 11:30 a.m. through 11:50 a.m. with resident 4 revealed: *There was a medication cup full of multiple pills on her bedside table. There were no staff in the resident's room at that time. *When the resident was asked what medications were in the medication cup, she stated that those were the pills that the nurse had given her. She was unable to tell me what medications were in the medication cup. *When asked if she was in pain, she stated she was always in pain. When asked to rate her pain she was unable to do so and seemed agitated. 2. Interview on 3/12/24 at 11:55 a.m. with certified nursing assistant/medication technician (CNA/MT) H regarding the medications that were left on resident 4's bedside table revealed: *She stated that those medications were her morning medications…

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 review of grievances, the provider failed to ensure staff interactions and services were provided in a manner that maintained a sense of dignity and respect for two of two sampled residents (144 and 252). Findings include: 1. Observation and interview on 12/14/23 at 3:40 p.m. with resident 252 revealed she: *Was in her room on the [NAME] wing eating a late lunch while seated in a wheelchair. *Had moved in on Thursday, 12/7/23, into a room on the East wing and then was moved to the [NAME] [Medicare A therapy] wing on 12/11/23. *Had been left completely on my own in her room after moving in, and felt like a non-entity. *Waited for a nurse to go over her medications with her and take her insulin to the refrigerator but she never saw a nurse until 4 a.m. *Had asked for the nurse to come in to take my blood sugar. I kept calling for the nurse to do it. The nurse was upset with me. I overheard her tell someone, 'Tell her I'll get there when I get there.' *Waited over…

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 grievance policy review, the provider failed to take steps to investigate all allegations reported by two of three sampled residents (144 and 252). Findings include: 1. Observation and interview on 12/14/23 at 3:40 p.m. with resident 252 revealed she: *Was in her room on the [NAME] wing eating a late lunch while seated in a wheelchair. *Had moved in on Thursday, 12/7/23, into a room on the East wing and then was moved to the [NAME] [Medicare A therapy] wing on 12/11/23. *Described multiple concerns she had experienced the first three days after moving in. *Had tears in her eyes and struggled to talk several times when describing her experience. (Refer to F 550, finding 1.) Review of the provider's grievance and satisfaction form dated 12/11/23 at 1:20 p.m. revealed: *Resident 252 had voiced a grievance by email on 12/10/23 at 4:53 p.m. to a healthcare provider, which had then been forwarded to the nursing home. *In addition to the concerns she described during…

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, complaint reviews, and policy review, the provider failed to ensure the facility was operated and administered by administrator A and director of nursing (DON) B, in a manner that ensured the safety and overall well-being of all 95 residents in the facility. Findings include: 1. Observations, interviews, record reviews, and policy reviews throughout the survey revealed administrator A and DON B had not ensured the safe management and overall well-being of all the residents who lived in the facility. This was evidenced by: *There was a widespread system breakdown to ensure the facility was free from accident hazards from the use of mechanical lifts, residents with elopement risks had been identified and interventions had been put in place for prevention. *Lack of staff education, monitoring, and communication to prevent facility acquired pressure injuries. *Concerns regarding the lack of communication available to staff to ensure appropriate care of the residents had been provided. *Responsiveness to residents choices for dietary…

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 observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all 95 residents in the facility. Findings include: 1. During the survey, from 10/31/23 through 11/2/23 and 11/6/23 through 11/9/23, the provider had not been operated in a manner to ensure the residents had received quality care. Refer to F561, F565, F623, F625, F656, F657, F658, F686, F689, F692, F725, F726, F756, F758, F802, F809, F835, and F880.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, resident grievance review, resident council minutes review, kitchen crew meeting minutes review, manager on duty checklist review, and policy review, the provider failed to support residents' choices for 22 of 53 sampled residents (5, 7, 11, 12, 19, 23, 28, 36, 38, 46, 53, 58, 62, 67, 71, 72, 73, 74, 81, 253, and two residents who had discharged prior to the survey) regarding menu options, condiments, beverages, and timely delivery of meal trays to residents who chose to eat in their rooms. Findings include: 1. Interview on 10/31/23 at 5:14 p.m. with resident 12 revealed: *He was unable to choose from the alternate menu. *The daily menu for lunch and dinner was listed in The Daily Chronicle, a newsletter the activities department supplied to the residents daily. *To order off the alternate menu, your choice for the lunch menu had to be given to the dietary personnel by 10:00 a.m. and by 3:00 p.m. for the dinner menu. *He was blind, so if no one read the menu to him, he was unable…

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, observation, review of resident council minutes, a resident council department response form, and policy review, the provider failed to promptly act upon grievances and provide a response for sixteen residents (5, 7, 12, 19, 23, 28, 38, 46, 53, 58, 62, 67, 71, 73, 74, and 81) who reported ongoing grievances regarding meal and snack service and response to call lights. Findings include: 1. Interview on 11/6/23 at 10:10 a.m. during a resident group interview with sixteen residents (5, 7, 12, 19, 23, 28, 38, 46, 53, 58, 62, 67, 71, 73, 74, and 81) who attended resident council meetings revealed there was consensus on the following concerns: *When asked if the nursing home acts promptly on grievances and provides a response to concerns that had been voiced by residents, the residents stated, -If it suits the nursing home, sometimes there will be an explanation. -A lot of times we just hear they are going to fix it. -They [staff] say, We're working on it. -Staff have bad attitudes, which was…

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 notify the Ombudsman regarding transfers initiated by the provider for four of four sampled residents (6, 9, 24, and 91). Findings include: 1. Review of the electronic medical record (EMR) for resident 24 revealed a Late Entry Incident Note dated 10/23/23 at 4:45 p.m., created on 10/24/23 at 7:40 p.m. that documented: *The nurse was called to the room by two certified nursing assistants (CNA) and observed the resident laying on the ground with the hoyer [Hoyer] sling beneath her. *The nurse asked the CNAs about the transfer and they stated the hoyer machine was tilting because the resident was leaning more to one side than the other on the hoyer sling. -No injuries were observed and no pain was reported at that time. Review of the facility investigation of the incident, completed on 10/27/23, revealed: *Resident 24 complained of pain in her left leg and head when she was laid down after dinner. *The provider was made aware of 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 record review, interview, and policy review, the provider failed to notify the resident or representative regarding the provider's bed-hold policy at the time of transfer for four of four sampled residents (6, 9, 24 and 91). Findings include: 1. Review of the electronic medical record (EMR) for resident 24 revealed a Late Entry Incident Note dated 10/23/23 at 4:45 p.m., created on 10/24/23 at 7:40 p.m. that documented: *The nurse was called to the room by two certified nursing assistants (CNA) and observed the resident laying on the ground with the hoyer sling beneath her. *The nurse asked the CNAs about the transfer and they stated the hoyer [Hoyer] machine was tilting because the resident was leaning more to one side than the other on the hoyer sling. -No injuries were observed and no pain was reported at that time. Review of the facility investigation of the incident, completed on 10/27/23, revealed: *Resident 24 complained of pain in her left leg and head when she was laid down after dinner. *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 care plans were revised to adequately address relevant needs and ensure accurate information for 8 of 31 sampled residents (1, 9, 10, 24, 64, 77, 87, 244). Findings include: 1. Observations and interviews on 11/2/23 at 9:52 a.m. and on 11/6/23 at 3:12 p.m. with resident 10 revealed he: *Was able to converse but his responses were not always consistent with the questions asked. *Had no complaints. *Was able to move about in his wheelchair. Review of the 10/13/23 quarterly MDS for resident 10 revealed: *His BIMS score was 3, which indicated he had severely impaired cognition. *No mood symptoms were coded. *The only behavior coded was rejection of care. Review of Behavior Notes between 8/22/22 - 11/1/23 revealed: *Multiple events of resident 10 exit seeking (wanting to go outside). *Staff response on most occasions was to redirect him away from the door and offer a snack. *In most instances, that intervention failed 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.

2. Interview on 11/6/23 at 3:52 p.m. with DON B revealed: *He agreed resident 193 was to have received eight ounces of a nutritional supplement daily. *Nursing documented the resident received the nutritional supplement. *Nursing documentation was based off of what dietary had documented on the intake record. *The amount of the nutritional supplement and other fluids the resident received were not recorded as separate entries in the intake record. Observation and interview on 11/8/23 at 9:30 a.m. dietary aide (DA) S revealed: *She was documenting the what the residents had eaten and drank. *DA's document the percentage of what was eaten and amount of fluids drank. *The fluids the resident drank included any nutritional supplement they were supposed to receive. *She stated the CNAs document what the assisted dining residents ate and drank. Interview on 11/8/23 at 9:45 a.m. with CNA P revealed she had assisted resident 193 with his breakfast this morning, He had not received any nutritional supplement to drink. Based on observation, interview, record review, and policy review, 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 interview, record review, and policy review, the provider failed to ensure the consultant pharmacist(s) communicated their recommendations to the residents physicians. Findings include: 1. Interview on 11/8/23 at 11:35 a.m. with licensed practical nurse (LPN) unit manager J revealed she: *Had only been in her current position since June 2023. *Received the pharmacists recommendations from director of nursing (DON) B each month. *Would send the consultant pharmacist recommendations to the residents physicians and wait for the response, *Was not sure if the consultant pharmacist also sent the recommendations to the residents physicians. *Did not have responses to the consultant pharmacists recommendations for resident 12: -Those recommendations included: --A 3/13/23 request for a gradual dose reduction of a psychoactive medication. --A 7/14/23 request for thyroid laboratory tests. --A 9/10/23 request for lipid (blood test that measures the amount of certain fat molecules) due to medication use. Interview on 11/8/23 at 3:46 p.m. with DON B and Regional Nurse Consultant (RNC)…

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 three of three (3, 12, and 33) sampled residents reviewed for unnecessary psychotropic (mood stabilizer) medications had a gradual dose reduction (GDR). Findings include: 1. Review of resident 12's consultant pharmacist monthly documentation revealed: *The consultant report indicated a recommendation had been made on 4/1/23. *The recommendations were not located in his electronic medical record. Interview on 11/8/23 at 11:35 a.m. with licensed practical nurse (LPN) unit manager J revealed she: *Was not aware of the consultant pharmacists recommendation to resident 12's physician for a gradual dose reduction of his psychoactive medications. *Received the pharmacists recommendations from director of nursing (DON) B each month. *Would send the consultant pharmacist recommendations to the residents physicians and wait for the response. Review of the consultant pharmacists 4/1/23 recommendations summary received from LPN/unit manager J on 11/8/23 at 2:30 p.m. revealed: *The recommendations summary…

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, observation, review of weekly schedule for dietary, Grievance and Satisfaction Forms, Resident Council Minutes, a Resident Council Department Response Form, minutes of Kitchen Crew Meetings, provider policy, and the Facility Assessment, the provider failed to have sufficient dietary personnel to ensure timely delivery of meal room trays and snacks for twenty residents (5, 7, 11, 12, 19, 23, 28, 36, 38, 46, 53, 58, 62, 67, 71, 73, 74, 81, and two discharged residents) who reported ongoing grievances regarding timely meal and snack services. (Refer to F 809.) Findings include: 1. Interview on 10/31/23 at 10:42 a.m. with dietary manager (DM) N revealed: *The lunch meal service started at 11:15 a.m. on the [NAME] unit, then the Center unit, then the East unit. *The supper meal service following the same rotation and started at 5:15 p.m. Observation and interview on 10/31/23 of the lunch meal service from 11:15 a.m. through 12:30 p.m. revealed: *At 11:15 a.m., in the [NAME] dining room, cook C…

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, review of Resident Council Minutes, Grievance and Satisfaction Forms, Kitchen Crew Meetings minutes, manager on duty documents, and policy review, the provider failed to ensure timely delivery of meal room trays and snacks for nineteen residents (5, 7, 12, 19, 23, 28, 36, 38, 46, 53, 58, 62, 67, 71, 73, 74, 81, and two discharged residents) who reported ongoing grievances regarding timely meal and snack service. Findings include: 1. Interview on 11/6/23 at 10:10 a.m. during a resident group meeting with sixteen residents (5, 7, 12, 19, 23, 28, 38, 46, 53, 58, 62, 67, 71, 73, 74, and 81) who attended resident council meetings revealed there was consensus that: *Room trays with meal items were not delivered timely to the resident rooms. *Some residents had gone without a breakfast or evening meal when they chose to eat in their rooms. *Snack carts were delivered to the nurses' stations, but snacks were not distributed. Residents would have to go to the cart to get a snack. Refer to F565. Review…

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 (75) who received dialysis comprehensive care plan included information on his dialysis access, type of diet, and parameters for fluctuations in his weight. Findings include: 1. Observation and interview on 11/2/23 at 3:30 p.m. with resident 75 revealed: *He had just returned from his dialysis treatment. *Has been receiving dialysis for about 6 years. *His dialysis treatments were scheduled on Tuesday, Thursday, and Saturday mornings at [provider name] dialysis. *He had an upper left chest central venous catheter dialysis access. There was an intact gauze dressing over the insertion site. *He stated the staff here do not take care of the dialysis access area. Interview on 11/6/23 at 10:00 a.m. with licensed practical nurse D revealed: *A communication sheet was sent with resident 75 when he went to dialysis. *When he returned the communication sheet is reviewed for any changes in his condition he might have had during his dialysis treatment. *His dialysis…

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 administer medications according to the physician's order for one of two sampled residents (84) during one of one medication pass with one of one certified medication aide (CMA) PP. Findings include: This requirement was NOT MET as evidenced by: 1. Observation on 11/7/23 at 7:50 a.m. with CMA PP administering medication to resident 84 revealed: *CNA PP was going to administer Klor-Con M20 Oral tablet Extended Release (potassium chloride microencapsulated crystals) after checking the medication against the November 2023 medication administration record (MAR). *The physician's order on the MAR indicated to administer 20 mEq (milliequivalent) by mouth one time a day for a supplement while on a diuretic (furosemide) for localized edema. *When asked when the resident had taken his furosemide CMA PP stated that the resident's furosemide had been discontinued. *CMA PP consulted with licensed practical nurse (LPN)/unit manager J and CMA PP was instructed to hold the medication and LPN J would consult…

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 infection control policies were adhered to with the following: *Appropriate hand hygiene and glove use by five of five certified nursing assistants (CNAs) X, U, I, K, and T during the provision of personal care for three of three sampled residents (9, 25, and 7). Findings include: 1. Observation on 10/31/23 at 11:29 a.m. with CNA X and CNA U getting resident 9 out of bed using a mechanical full-body lift revealed: *CNA X had removed her gloves without performing hand hygiene and applied a new pair of gloves. *Staff attempted to raise the resident out of the bed and the resident slide out and onto her bed the straps were crossed between her legs. *CNA X had removed her gloves. *CNA X applied a new pair of gloves and assisted with changing resident 9's incontinent brief. *CNA X performed peri-care and with her gloved hands: -Rolled resident over to her left side to remove the old incontinent brief. -Continued to perform peri-care and removed the old incontinent brief. -Placed a clean brief under 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, and policy review, the provider failed to ensure: *One of one carpeted wing (300 east) had carpet that was free from multiple stains. *Thirteen of thirty resident bathroom doors (rooms 302, 305, 308, 309, 311, 312, 315, 318, 319, 325, 326, 327, and 328) were free from scratches and gouges to prevent resident injuries. Findings include: 1. Observation and interview on 10/3/23 at 8:57 a.m. with environmental consultant J on the 300 wing revealed: *He was in the building to train the newly hired maintenance director D. *He was the consultant for fifteen buildings. *The provider worked on environmental issues as they were identified. *He agreed the carpet in the 300 wing had multiple stains. 2. Interview on 10/3/23 at 9:05 a.m. with maintenance director D on the 300 wing revealed: *He had been in his position for eight weeks. *He was working with environmental consultant J on addressing issues in the building. *He agreed the carpet in the 300 wing was stained by most of the resident…

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 Surveyor: [NAME], [NAME] Based on observation, interview, record review, and policy review, the provider failed to meet the bathing and toileting needs for 4 of 5 sampled residents (4, 5, 9, and 10). Findings include: 1. Observation and interview on 10/3/23 at 4:55 p.m. with resident 4 revealed: *She was in bed with the head of the bed raised so that she was sitting upright. *An over-the-bed table on wheels was positioned in front of her and above her legs. *A portable commode was setting on the floor at the foot of the bed and in front of the bathroom door. *She had been told by staff to eliminate her urine and bowels into her brief, but I cannot do that, it is not right. *She preferred to be transferred onto the commode or into the bathroom and onto the toilet to urinate or have a bowel movement. *She felt very good when she recently had been able to have a bowel movement while sitting on the commode. Review of resident 4's 8/11/23 significant change Minimum Data Set (MDS) revealed: *A Brief Interview 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.