Bethany Home Sioux Falls

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 for one of one discharged sampled resident (57) who eloped (left the facility without staff knowledge) from the front door of the facility on 8/29/25 and was reported to the facility by a community member. The facility's front door was not alarmed or monitored at that time of the resident's elopement. Findings include:1. Review of the provider's 9/2/25 SD DOH FRI involving resident 57 revealed:*On 8/29/25 at approximately 5:10 p.m., a community member called the facility to tell staff that the resident was at their home, a block away from the facility.*The staff had last seen the resident at approximately 4:00 p.m.*According to the provider's investigation, the resident left the facility at approximately 4:06 p.m. and walked to the community member's home. She had knocked on the community member's door, and they sat with her until a facility…

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) review, interview, record review, and policy review, the provider failed to ensure one of one licensed practical nurse (LPN) G followed facility policy, practiced within his scope of practice, and sought direction from a registered nurse (RN) or physician for one of one sampled resident (1) related to the family's concerns of the resident having a low hemoglobin blood level (protein in the red blood cells that carries oxygen). Findings include: 1. Review of the provider's 6/28/25 FRI submitted by the provider to the SD DOH regarding resident 1 revealed on 6/28/25 at around 7:40 p.m. LPN G documented a nursing progress note that stated Resident's daughter is concerned of possible gastrointestinal bleed (GI) due to stool being black and past like. I informed daughter its likely due to new medications but will update chart to bring light to the subject. There was no documentation to support that LPN G had assessed resident 1,…

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 menu review, observation, and interview, the provider failed to ensure adequate portions were served according to the menu for one of one observed meal. This had the potential to affect all residents receiving the main menu in the facility. Findings include: 1. Review of the provider's menu for lunch on 11/7/24 revealed the following main menu items: *Beef & broccoli, #8 dip x2, which was eight ounces (oz.) total. *Diced carrots, four oz. spoodle. -A spoodle is a slotted scoop to drain the liquid. 2. Observation on 11/7/24 at 11:11 a.m. in the kitchen during lunch service revealed: *Cook L was plating the residents' lunch meal food items. *She served a three oz. scoop of the beef & broccoli. -The printed menu indicated the serving size for the regular diet as #8 dip x 2. *Cook L served a heaping two oz. spoodle of diced carrots. -The printed menu indicated the serving size as 4 oz. *Observation of the utensil drawer confirmed that a 4 oz. spoodle and a 4 oz. serving spoon were available. 3. Interview on 11/7/24 at 1:29 p.m. with cook L revealed she: *Was 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.

Based on observation, interview, and document review, the facility failed to maintain cleanliness in one of one steamer and one of one convection oven in the kitchen. Findings include: 1. Observation during the initial kitchen tour on 11/5/24 from 11:43 a.m. to 12:19 p.m. revealed: *The interior of the Vulcan brand convection oven was heavily coated in baked-on grease and food particles. *The interior of the Cleveland brand SteamChef steamer had an excessive buildup of limescale and scum, and there were food particles at the bottom of the basin sitting in standing water. 2. Interview on 11/7/24 at 10:45 a.m. with cook L about cleaning the large kitchen equipment revealed: *She claimed that she cleaned the steamer and oven every day, and deep-cleaned them weekly. *That equipment had not been deep-cleaned in about a month. *She did not know the proper steps to clean the steamer. 3. Interview on 11/7/24 at 1:34 p.m. with dietary manager G about the oven and steamer revealed: *There was a cleaning schedule for the kitchen equipment. *She performed monthly audits for kitchen cleanliness.…

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 policy review, the provider failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for one of three (247) sampled residents. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incident. Findings include: Review of provider's documentation regarding advanced beneficiary notices (ABN) revealed on 10/11/24, the provider identified previous social worker (SW) O had not been completing SNF ABNs or NOMNCs for residents who received Medicare Part A skilled services. *Administrator A interviewed (SW) O and SW P on 10/16/24. -SW O had reported he was not trained upon his hiring on how to complete the ABNs by SW P. -SW P had reported she had trained SW O upon his hiring on how to complete the ABNs. Record review on 11/6/24 of the provider's SNF Beneficiary Notification Review Form CMS-20052 revealed: *Three randomly selected residents were given to the provider for review of SNF ABN. *Resident 247's Medicare A skilled…

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 ensure 25 of 25 sampled residents on Promise Lane (1,2,3,5,6,7,8, 9, 10, 11,12, 13, 14, 20, 21, 22, 23, 25, 26, 27, 28, 36, 38, 39, and 40) had their blood sugar checked and received treatment and medications as ordered by one of one registered nurse (RN) F during a twelve-hour shift. Findings include: 1. Review of SD DOH FRI submitted on 10/9/24 revealed: *On 10/6/24 RN F had left her unit from 9:00 a.m. until 11:00 a.m. and staff were unable to locate her during this time. *Certified nursing assistant (CNA)/medication aide N had to remind RN F multiple times to give morning narcotics for three residents, but she never saw RN F go in or out of those rooms to give those medications, but they were signed off. 2. Review of the provider's investigation documentation indicated the 10/6/24 video camera footage was reviewed and revealed RN F: *RN [NAME] the unit 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.

Based on interview and record review, the provider failed to provide a written notice of transfer or discharge and to notify the ombudsman of that transfer or discharge, for two of two sampled residents reviewed (31 and 45). This citation is considered past non-compliance based on review of the corrective actions the provider implemented after discovering the lack of documentation. Findings include: 1. Interview and record review on 11/5/24 at 11:51 a.m. with administrator A revealed: *Administrator A provided the survey team with a copy of their investigation timeline and their plan of correction (POC) documentation. *They discovered a lack of documentation for a variety of required notices on 10/11/24. *The management team completed an investigation to determine the extent of the issue. *The previous social worker was responsible for providing required notices to residents or their representatives. That former employee was not providing the required written notices, including transfer or discharge notices. *The nurse managers were educated on the required written notices on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the provider failed to provide a written bed-hold notice to the resident or their representative when transferred to the emergency department for one of two sampled residents reviewed (45). This citation is considered past non-compliance based on review of the corrective actions the provider implemented after discovering the lack of documentation. Findings include: 1. Interview and record review on 11/5/24 at 11:51 a.m. with administrator A revealed: *Administrator A provided the survey team with a copy of their investigation timeline and plan of correction (POC) documentation. *They discovered a lack of documentation for a variety of required notices on 10/11/24. *The management team completed an investigation to determine the extent of the issue. *The previous social worker was responsible for providing required notices to residents. That former employee was not providing the required written notices, including bed hold notices. *The nurse managers were educated 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 record review, interview, and policy review, the provider failed to ensure the care plan for two of two sampled residents (11and 25) had been updated to reflect their current condition. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *On 8/6/24 she had received a diagnosis for dementia and other diseases classified elsewhere. *On 8/15/24 an order had been received to start Seroquel 100 milligram (mg) by mouth one time a day related to Major Depressive Disorder. 2. Review of resident 11's care plan revealed: *On 8/20/24 the care plan had been updated and indicated the use of scheduled psychotropic medications related to pain management and depression. No focus area on resident's diagnosis of dementia was noted in the care plan. 3. Review of resident 25' s EMR revealed: *On 8/23/24 an order had been received to start Apixaban 2.5 mg (blood thinner) for Atrial fibrillation by mouth two times per day for blood clot prevention. 4. Review of resident 25's care plan revealed: *On 10/29/24 the care plan had been updated but did not indicate…

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: *Ensuring one of one resident (304) had performed hand hygiene after he had touched his blood from a wound on his arm prior to having the resident sign his name in the narcotics binder. *Establishing a water management program that addressed the prevention of Legionella. Findings include: 1. Observation and interview on 7/20/23 at 8:42 a.m. with licensed practical nurse (LPN) E during medication administration revealed: *She had prepared medications for resident 304. *She donned clean gloves. *She grabbed the narcotics binder from the locked narcotics drawer in the medication cart. -There were several different types of narcotics that were prescribed for different residents. -The binder sat on top of the medications. *Upon entering the resident's room, the resident was found to have been bleeding from his right upper arm. -With his left hand, he pressed a piece of tissue paper to the small bleeding wound. -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.

Based on observation, interview, record review, and policy review, the provider failed to ensure medication prescription labels were accurate with the most recent physician's orders for two of twenty-eight medication labels reviewed. Findings include: 1. Observation and interview on 7/20/23 at 8:03 a.m. with licensed practical nurse (LPN) E during medication administration revealed: *She was preparing medications for resident 27. *She grabbed the resident's bottle of MiraLAX. -The prescription label had the following directions: MiraLAX 17g [grams] in liquid by mouth every day as needed. *When she checked the physician's order for resident 27's MiraLAX, she found that there were two different orders for MiraLAX. -One order read, MiraLax Oral Packet (Polyethylene Glycol 3350) Give 8.5 gram by mouth one time a day for constipation. --LPN E confirmed there were only bulk bottles of resident 27's powdered MiraLAX, and there were no oral packets as the physician's order called for. -The other order read, MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 17 gram by mouth…

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 Minimum Data Set (MDS) discharge assessments were completed in a timely manner for two of two sampled residents (4 and 36). Findings include: 1. Review of the MDS transmission results summary report on 7/20/2023 provided by MDS coordinator C who was also the assistant director of nursing (ADON) revealed no discharge assessments had been submitted for residents 4 who had been discharged home on 1/28/23 and resident 36 who had been discharged home on 2/10/23. Review of the Resident Assessment Instrument (RAI) manual revealed discharge assessments when a resident's return was not anticipated were to have been submitted no later than fourteen days after a resident discharged . Review of the providers 7/2017 MDS Completion and Submission Timeframes policy revealed: *Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. -1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS'…

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.