Bethany Home - Brandon
Non profit - Corporation
60 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
26/100
#77 of 95 in SD
Photo by Bethany Meadows
Photo by Bethany Meadows
Photo by Bethany Meadows
1 / 5 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bethany Home in Brandon has received a Trust Grade of F, indicating poor quality and significant concerns. It ranks #77 out of 95 facilities in South Dakota, placing it in the bottom half, and #7 out of 9 in Minnehaha County, meaning only two local options are considered better. While the facility's trend is improving, with issues decreasing from 6 in 2024 to 3 in 2025, there remain serious weaknesses, including a critical finding related to food safety that poses a risk of foodborne illnesses for residents. Staffing is a strength, with a 5/5 star rating and a turnover rate of 42%, which is below the state average. However, the facility has accumulated $24,385 in fines, suggesting some compliance issues, and it has less RN coverage than 76% of facilities in South Dakota, which is concerning given the facility's other deficits.
- Trust Score
- F
- In South Dakota
- #77/95
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near South Dakota's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $24,385 in fines. Higher than 82% of South Dakota facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for South Dakota. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
26/100
Bottom 19%
Review needed
6 → 3 violations
★☆☆☆☆
1.0
Overall Rating
★★★★★
5.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 3 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below South Dakota average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
1-Star Overall Rating
Below South Dakota average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 42%
Near South Dakota avg (46%)
Typical for the industry
Federal Fines: $24,385
Below median ($33,413)
Minor penalties assessed
The Ugly 15 deficiencies on record
1 life-threatening 1 actual harm
May 2025
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**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 revie...
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**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 the safety of one of one sampled resident (3) who fell out of her wheelchair and received a laceration to the left side of her forehead that required sutures. The fall was related to assistive devices (wheelchair pedals) not being in place to prevent an accident.
Findings include:
1. Review of the provider's 3/15/25 SD DOH FRI regarding resident 3 revealed:
*On 3/15/25 at 8:30 a.m. certified nursing assistant (CNA) Q yelled out while in resident 3's room.
*CNA D responded and went to assist resident 3 in her room and alerted licensed practical nurse (LPN) R that resident 3 was on the floor.
*LPN R entered the room and found resident 3 lying on the floor on her left side and bleeding from the left side of her forehead from an approximately ½ inch laceration with immediate swelling/bruising to forehead with bleeding unable to be controlled with pressure at this time.
*911 called and resident [was] picked up via ambulance.
*[Resident 3] returned with sutures in her head.
*Resident's fall was due to no wheelchair petals [pedals] on her wheelchair.
2. Review of resident 3's closed electronic medical record (EMR) revealed:
*She was admitted to the facility on [DATE].
*Her diagnoses included traumatic subdural hemorrhage with loss of consciousness, repeated falls, and unspecified dementia with other behavioral disturbance.
*Her 3/5/25 Brief Interview for Mental Status (BIMS) assessment score was ten which indicated she was moderately cognitively impaired.
*A progress note on 3/15/25 at 11:49 a.m. indicated:
-Writer heard CNA yell out while in resident's room. 2nd CNA went to assist and alerted writer that resident was on the floor. Upon entering the room, resident was laying on left side and bleeding from left side of forehead. CNA applied pressure to wound after writer assessed wound. Noted approximately half inch laceration with immediate swelling/bruising to forehead with bleeding unable to be controlled with pressure at this time. Assessed noted injury, .
*A progress note on 3/15/25 at 2:15 p.m. indicated:
-Resident returns from ED [emergency department] at 1345 [1:45 p.m.] via wheelchair express. Paperwork returned to writer . Generally confused at this time. Resident received 3 sutures to [her] left forehead. Will continue neuro [neurological] checks for fall/hitting head.
*Her comprehensive care plan revealed:
-A focus area that indicated I am at risk for falls.
-Interventions that included:
--I have reported 4-5 falls in the past 6 months, one of which resulted in my subdural hematoma and is why I am here at [provider's name].
--I suffered a witnessed fall . on 3/15 that resulted in an injury to my head. I was transported to the hospital for evaluation. I fell forward out of my wheelchair as I was being propelled by staff .
*On 5/6/25, resident 3 was transferred to another nursing home.
3. Interview on 5/29/25 at 11:36 a.m. with CNA D revealed:
*She had worked at the facility since August 2024.
*Regarding how to ensure the safety of residents using wheelchairs she stated Wheelchair pedals, those are a must and stated they had an incident related to that a couple of months ago.
*Regarding that incident, she stated:
-She worked the morning of 3/15/25 with another CNA Q and was serving breakfast when she heard a gasp, and she walked into the room and found resident 3 on the floor.
-CNA Q stated to her that she did not know what happened.
-CNA D stated that resident 3 needed wheelchair pedals as she could walk and would often propel herself in her wheelchair, and her would catch on the floor when transporting her in her wheelchair without the pedals.
-She stated CNA Q had been working at the facility longer than she had, so she should have known that.
-She stated there was training provided following that incident that included reading and signing an information sheet regarding the importance of using wheelchair pedals with residents.
Interview on 5/29/25 at 3:00 p.m. with director of nursing (DON) A revealed:
*She stated the training on the use of wheelchair foot pedals with residents was provided on 3/15/25.
*She expected staff to use wheelchair pedals with residents while transporting them.
*No monitoring mechanism had been put in place to ensure staff used wheelchair pedals when transporting residents.
*She stated that during her daily rounds she had observed to ensure foot pedals were in use on residents' wheelchair, but she had not documented those observations.
Interview on 5/29/25 at 3:39 p.m. with LPN R revealed:
*She recalled resident 3 and the incident that occurred on 3/15/25.
*She had heard CNA Q yell out in surprise.
*CNA D then stated, She's on the floor.
*LPN R entered resident 3's room to assess the resident.
*She stated resident 3 was on the floor in front of her wheelchair.
*There was bleeding on the left side of her forehead and she could tell she needed stitches.
*She had not worked much with CNA Q.
*She indicated that CNA Q stated resident 3 had just fallen forward out of her wheelchair.
*She stated she had called DON A to let her know about the situation as the resident went to the emergency department.
*She stated that DON A had contacted her later that afternoon to ask if she had checked the wheelchair to ensure the foot pedals had been used.
*LPN R stated she went to look at resident 3's wheelchair and discovered there were no foot pedals on her wheelchair.
*LPN R stated the use wheelchair pedals was common sense.
*She felt the provider had addressed the situation appropriately as they immediately suspended CNA Q and then ended up terminating her employment.
*She recalled that written education regarding the required use foot pedals was provided and that it had been addressed at the next staff meeting.
4. Review of the provider's 2/2/21 Use of Wheelchair Pedals policy revealed:
*Purpose: To ensure each resident who uses a wheelchair had wheelchair foot pedals available and used properly to prevent accidents.
*Foot pedals will be used for residents who use wheelchairs while they are in their wheelchair, unless deemed safe and care planned otherwise.
*Foot pedals will be provided for each wheelchair used by a resident for mobility.
Review of the requested list of the current 54 residents revealed 48 of those residents required the use of a wheelchair.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI)reviews, observation, interview, record r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI)reviews, observation, interview, record review, and policy review, the provider failed to protect the resident's right to be free from verbal and physical abuse by certified nursing assistant (CNA) K while providing assistance with undressing to one of one cognitively impaired sampled resident (1) dependent on staff assistance for activities of daily living (ADLs) and known resistance to care.
Findings include:
1. Review of the provider's 1/20/25 submitted SD DOH FRI regarding certified nursing assistant (CNA) K's interaction with resident 1 revealed:
*Resident 1 had poor cognition and resided in the secured memory care unit.
*On the evening of 1/19/25 [CNA K] was getting resident 1 ready for bed .
*CNA K [did not know I CNA/certified medication aide(CMA) L] had walked into the room and she [CNA K] was getting frustrated because [resident 1] did not want to take off his sweater .
*CNA K was getting upset and was taking his [resident 1's] arm out of his sweatshirt aggressively and he verbally said 'ow'.
* .DON [director of nursing (DON) A] spoke with [CNA K] regarding the above incident.
-[CNA K] states she went into [resident 1's] room around [9:00 p.m.] to get him ready for bed.
-She [CNA K] states [resident 1] starts hitting and kicking her. [CNA K] states she told [resident 1], 'no, I don't want to be hit.'
-[CNA K] states she was able to get [resident 1]'s shirt off, but then had to pry it out of his hands. -When questioned if he said 'ow' at any point, [CNA K] states he did when she pulled the shirt out of his hands.
-[Resident 1] continued to hit and kick [CNA K], and [CNA K] states she told [resident 1] she was not having this.
-[CNA K] states she was eventually able to get [resident 1] into bed.
-DON A informed [CNA K] she was suspended pending completion of the investigation.
*Investigation Conclusion:
-Incident was reported on 1/19/2025 at 10:37 p.m., however this was not seen by DON [A] until the following day as it was reported via text message.
-[CNA K] was suspended on 1/20/2025 at noon.
-Resident [1] was assessed on 1/20/25 by the floor nurse. No injuries noted. No adverse effects noted. No signs of distress or fearfulness noted. Resident was not interviewed as he has poor cognition and would not understand.
-No other residents were interviewed as this incident occurred on our secured memory care unit where all residents would not be able to recall.
-No other staff members were interviewed as [CNA L] was the only other staff member actively working with the residents on that neighborhood.
-Nursing and administration is looking into dementia education programs and will be doing written education with all nursing staff on abuse and neglect.
-Will continue to monitor.
-The question Was abuse allegation substantiated? was answered Yes.
-[CNA K]'s statement acknowledged abuse.
-Personnel terminated was documented in the action taken by facility area of the report.
Observation on 5/29/25 at 8:48 a.m. of resident 1 in the memory care unit (MCU)'s dining room revealed:
*He sat in his wheelchair and self-propelled his wheelchair around the dining room.
*He was pleasantly confused and responded to a greeting, shook hands and responded to simple questions by laughing.
Review of resident 1's electronic medical record (EMR) revealed:
*He was admitted to the facility on [DATE] to a room in the MCU.
*His diagnoses included: Alzheimer's disease with late onset and moderate dementia, with other behavioral disturbance.
*His current care plan included interventions:
-If resident resists with ADLs [activities of daily living], reassure resident, leave and return 5-10 minutes later and try again.
-I require staff assistance with all transfers with use of standing lift.
-I require staff assistance with all dressing, grooming, toileting and personal care tasks.
*His 4/3/25 Brief Interview for Mental Status (BIMS) assessment score was zero indicated severe cognitive impairment.
*A progress note on 1/20/25 at 7:46 a.m. indicated Resident's skin assessed, no lumps, bumps or bruising present to upper extremities. Resident has full range of motion to BUE [bilateral upper extremities]. Does have small less than pea sized scab to right outer forearm. No redness or bruising surrounding. Resident does not appear to be pain or discomfort with passive range of motion.
*There was no progress note related to the 1/19/25 incident noted above in the 1/20/25 submitted SD DOH FRI.
Interview on 5/29/25 at 9:04 a.m. with CNA P in the MCU regarding resident 1 revealed:
*He had worked at the facility since August 2024.
*Resident 1 was not responsive most of the time but responded to conversation at times.
*He felt resident 1 was pretty good this morning.
*He recalled only one time that resident 1 was resistive to care and CNA P got out of [the] way and let him cool off.
Interview on 5/29/25 at 11:36 a.m. with CNA D revealed:
*She had worked at the facility since August 2024.
*She felt no residents in particular were resistive to care in the MCU.
*She felt resident's 1's reactions depended on How you speak to him and interact with him.
*If a resident was resistive to care, she stated if she could not calm the resident down, she would leave and reapproach the resident later, and added that five minutes later could make a big difference.
Phone interview on 5/29/25 at 1:15 p.m. with CNA/CMA L revealed:
*She had worked full-time on the night shift at the facility until recently.
*She really enjoyed working on the MCU.
*She stated a few of the residents on the MCU had mood or behavior problems and required redirection.
* She stated some residents were resistive to care, but after giving the resident some time and reapproaching the resident later was most successful.
Continued interview with CNA/CMA L regarding the incident on 1/19/25 with resident 1 and CNA K revealed:
*It was her first time working with CNA K on 1/19/25.
*She worked with CNA K from 8:00 p.m. to 10:00 p.m. that night.
*She could not recall the exact time of the incident she observed, but stated she thought it was between 8:00 p.m. and 9:00 p.m.
*She noticed CNA K had brought resident 1 to his room.
*CNA/CMA L entered resident 1's room to place the unplugged cord for the sit-to-stand mechanical lift that was lying on the ground back on the lift.
*CNA K had not noticed CNA/CMA L in the room. CNA K was trying to get resident 1's shirt off and was visibly getting frustrated with him. CNA K yanked, on resident 1's arm to get his shirt off and stated, come on [resident 1's first name] and as he grabbed the shirt, CNA K tried to pry the shirt out of his hands.
*Resident 1 exclaimed ow in response to CNA K's actions.
*CNA/CMA L stated, I was very uncomfortable with what I had observed.
*CNA/CMA L felt after CNA K noticed CNA/CMA L in the room, CNA K tried to act differently and like she had not gotten upset with resident 1.
*She questioned if she should have confronted CNA K or if she should have had a supervisor confront her.
*After CNA K ended her shift and left the facility sometime after 10:00 p.m. that evening, CNA/CMA L asked the other medication aide on the MCU about the wording she had used in the text message to DON A about the incident.
*She had not been in a situation of observing another CNA potentially verbally and physically abusing a resident before that incident on 1/19/25.
*CNA/CMA L stated that DON A replied to her text message at 6:00 a.m. the next morning.
Interview on 5/29/25 at 3:00 p.m. with DON A revealed:
*CNA/CMA L's 1/19/25 text message was at 10:37 p.m. regarding the incident with CNA K and resident 1.
*She had replied to that text message on 1/20/25 at 6:52 a.m. over eight hours later.
*She expected staff to immediately inform the on-call nurse of allegations of potential abuse so the situation could be dealt with immediately
*She stated, during the investigation of the incident, she had educated CNA/CMA L of the need to immediately report an incident by calling the on-call nurse.
*Since the incident, no monitoring mechanisms were put in place to ensure staff notified the on-call nurse of suspected incidents of abuse if the DON was not in the building.
Further interview on 5/29/25 at 5:12 p.m. with DON A revealed:
*They had discussed dementia training for the staff with the regional ombudsman.
*They had not scheduled or set up that dementia training.
Review of the provider's 11/18/22 Resident Rights Guidelines revealed:
*Purpose: To provide general guidelines for resident rights while caring for the resident.
*Preparation: Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including:
-Be free from verbal, .physical, and mental abuse . from anyone .
*General Guidelines: .Ask permission to implement the procedure. If the resident refuses, notify your supervisor.
Review of the provider's May 2025 Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy revealed:
*If resident abuse, . is suspected, the suspicion must be reported immediately to the Director of Nursing (DON) or designee.
B. Based on SD DOH, FRI dated 4/29/25, record review, interview and policy review, the provider failed to protect the resident's right to be free from neglect by certified nursing assistant (CNA) F who left one of one cognitively impaired sampled resident (2) dependent on staff assistance with toileting needs and repositioning on a bedpan for an extended period of time that contributed to the resident developing a skin injury.
Findings include:
2. Review of the provider's SD DOH FRI dated 4/29/25 with attached baseline care plan revealed:
*This was a FRI for suspicion of abuse or neglect.
*Resident 2 was found on a bedpan on 4/29/25 at 9:00 a.m.
*Linear lines were noted on the resident's buttock that were slow to blanch (skin whitens in color temporarily/lacking blood flow to area).
*Day shift staff indicated they had not placed resident 2 on a bedpan yet that day.
*During nursing change of shift report the morning of 4/29/25 there was no indication that resident 2 was put onto a bedpan.
*The provider's investigation indicated certified nursing assistant (CNA) F reported she had placed resident 2 on a bedpan around 2:00 a.m. that day.
*CNA F was suspended on 4/30/25 pending further investigation by the provider.
*The resident's primary care provider (PCP) and power of attorney (POA) were notified of the incident.
*Resident 2's baseline care plan indicated:
-She needed a Hoyer lift (mechanical lift and sling to lift a person's full body) for all transfers.
-She used her wheelchair for mobility that was pushed by staff.
-She was unable to ambulate.
-She slept on a pressure guard mattress and sat on a pressure-reducing cushion in her wheelchair.
-She was continent of bowel and bladder.
-She used a bedpan for elimination of her bowel and bladder and required total staff assistance with her incontinence care.
-Staff were to encourage her to reposition frequently to promote my skin health.
-I am unable to take a bath currently, due to my surgical incision. Please assist me with bed bath twice weekly and as needed.
-I am receiving hospice services currently.
Review of resident 2's of electronic medical record (EMR) revealed:
*She was admitted to the facility on [DATE] and admitted to hospice services 4/22/25.
*Her diagnoses included:
-Acute Kidney Failure.
-Weakness.
*Her 4/22/25 Brief Interview for Mental Status (BIMS) assessment score was 6 which indicated she had severe cognitive impairment.
Resident 2's tasks (care needs provided by staff) included staff were to provide her:
-Repositioning as needed (PRN).
-She wore an incontinent brief.
-Toileting hygiene every day, evening, and night shift.
*Her toileting task by the staff was documented as completed at 2:27 a.m. on 4/29/25.
*A new physician's order was added 4/30/25 for Triad paste (a wound healing product) to her left buttock daily and PRN.
*A progress note dated 4/30/25 indicated:
-She had been left on a bedpan the previous day.
-Linear markings to her left buttock were parallel to each other, which would be consistent with the edge of a bedpan.
-Those areas on her left buttock were slow to blanch.
-An order to apply Triad paste to her left buttock was received and started.
*Resident 2 passed away on 5/1/25.
Interview on 5/29/25 at 2:32 p.m. with CNA F revealed:
*Resident 2 was unable to reposition herself.
*Resident 2 could use her call light to call for staff assistance.
*The resident was on a repositioning schedule and was to be repositioned by the staff every two hours.
*She had placed resident 2 on the bedpan between 2:00 a.m. and 3:00 a.m. on 4/29/25.
*She then answered two additional resident's call lights.
*She had forgotten she had placed resident 2 on the bedpan that day.
*She was suspended from work during an investigation of the incident.
*She completed the required education related to the incident prior to returning to working for provider.
Interview on 5/29/25 at 2:45 p.m. with registered nurse (RN) G revealed:
*She had worked on 4/28/25 at 6:00 p.m. until 4/29/25 at 6:00 a.m.
*She had given resident 2 medication for pain between 8:00 p.m. and 10:00 p.m. on 4/28/25.
*CNA F did not report to her that resident 2 was on a bedpan during that night shift.
*She had not attended any education regarding the use of bedpans for residents.
*Timers were to be used for up to 30 minutes when placing residents on bedpans to remind staff to check on the resident for removal of the bedpan.
*Residents needed to have call lights within reach.
Interview on 5/29/25 at 3:30 p.m. with CNA B revealed:
*She worked the morning shift on 4/29/25 that started at 6:00 a.m.
*Upon coming onto her shift, she walked around and checked on all of the residents.
*She got a report of the resident's status from the previous shift.
*She was told resident 2 had been changed at 5:00 a.m.
*She went into resident 2's room to complete her morning cares at 8:00 a.m. on 4/29/25 and discovered the resident was on the bedpan.
*After rolling her off the bedpan she observed a red mark on the resident's left buttock.
-There were no open areas on the resident's skin at that time.
*She recalled resident 2 had a previous deep tissue injury (DTI) on her coccyx when she had admitted to the facility.
*She reported the incident of the bed pan and red mark on the resident's buttock to licensed practical nurse (LPN) C.
Interview on 5/29/25 at 3:50 p.m. with LPN C revealed:
*She was the day nurse on 4/29/25 for resident 2's wing.
*She gave resident 2 her morning medications between 6:30 a.m. and 7:00 a.m. on 4/29/25.
*That morning CNA B told her that resident 2 had been found on the bedpan, she was unsure of the time.
*LPN C and assistant director of nursing (ADON)/Minimum Data Set (MDS) H assessed resident 2's buttocks after CNA B reported the concern to them.
*LPN C did not see a red circle from the bedpan at that time, but the resident's coccyx (tailbone) had a couple of red areas above it that were slow to blanch.
*A request was then sent to resident's PCP for Triad paste and foam to apply to the affected area.
Interview on 5/29/25 at 3:52 p.m. with ADON/MDS H revealed:
*She and LPN C assessed resident 2's buttocks on 4/29/25 after CNA B reported the concern to them.
*She observed an initial linear red mark, possibly from the bedpan being left under the resident too long, on resident 2's buttocks.
*No open areas or bleeding were noted at that time.
*Resident 2 had a previous DTI to her coccyx when she admitted to the facility.
*She had faxed resident 2's PCP and described what she found and what had occurred following the assessment to obtain a skin treatment order.
Interview on 5/29/25 at 5:20 p.m. with director of nursing (DON) A revealed:
*Bedpan education was given to the staff after the incident with resident 2 on 4/29/25.
-Timers were to be used for residents who used a bedpan.
-Staff were to set the timer for 10 minutes and check on the resident. If an additional 10 minutes was needed, then timer was to be reset.
-That process was implemented to ensure staff returned to assist the residents.
Review of the providers approved May 2025 Abuse, Neglect, Exploitation or Misappropriation Policy revealed:
*All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.
-a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
-b. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, and interview, the provider failed to ensure correct documentation of controlled medications (medic...
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Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, and interview, the provider failed to ensure correct documentation of controlled medications (medications with risk for abuse and addiction) when administered for one of one sampled resident (4). 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 provider's 2/6/25 SD DOH FRI for resident 4 revealed:
*Director of nursing (DON) A was notified by registered nurse (RN) E of concerns regarding licensed practical nurse (LPN) S that included:
-LPN S having left controlled medications sitting on top of a medication cart and unattended.
-LPN S having incorrectly documented the administration of resident 4's controlled medications.
*Initial evaluation of narcotic sheets showed LPN S had signed out three doses of lorazepam (a controlled antianxiety medication) 0.5 mg tablets on 2/5/25 at 9:00 a.m., 10:00 a.m., and 12:00 p.m.
-That medication card contained 29 tablets of lorazepam 0.5 mg tablets, while the controlled drug receipt/record/disposition form stated the count was 26 tablets.
*The oxycodone (a controlled pain medication) 5 mg half- tablets medication card contained 26 half-tablets. The narcotic (controlled medication) count sheet for the oxycodone stated the count was 29 tablets.
*Review of the resident's February medication administration record (MAR) revealed:
-LPN S signed out an as needed (PRN) dose of oxycodone at 10:16 a.m. on 2/5/25.
-LPN S signed out an PRN dose of oxycodone at 12:30 p.m. on 2/5/25.
-LPN S did not document any lorazepam medication was administered in the MAR on 2/5/25.
-LPN S did documented a scheduled lorazepam tablet was administered at 2:37 p.m. on 2/5/25.
-The MAR indicated a 2/5/25 at 3:00 a.m. dose of oxycodone 5 mg half-tablet was administered but, it was not signed out in the controlled drug receipt/record/disposition form by RN N.
*A narcotic medication count took place on 2/5/25 at 6:00 a.m. with RN N and LPN S, and no discrepancies in the medication counts were noted by them, despite a missing signature for a 3:00 a.m. dose of PRN oxycodone that was given by RN N.
*Narcotic counts on 2/5/25 at 4:00 p.m. between RN E and LPN S occurred and, RN E indicated LPN S needed to sign off her narcotic book.
*It was undetermined if LPN S signed the narcotic book at the time of the request.
*A narcotic count took place on 2/6/25 at 12:00 a.m. with RN E and LPN O with no discrepancies noted.
*A narcotic count took place on 2/6/25 at 6:00 a.m. with LPN O and LPN S with no discrepancies noted.
*Through the provider's investigation it was determined:
-RN N had administered a dose of oxycodone to resident 4 on 2/5/25 and did not sign out that dose on the receipt/record/disposition form.
-LPN S admitted she had incorrectly signed out three oxycodone doses under resident 4's lorazepam receipt/record/disposition form.
-LPN S admitted she had not documented the administration of that medication in the MAR.
-LPN S was placed on suspension on 2/6/25 pending completion of the provider's investigation.
-LPN S employment at the facility was terminated on 2/6/25 following the completion of the provider's investigation.
2. Interview on 5/29/25 at 2:20 p.m. with RN E revealed:
*On 2/5/25 her shift started at 4:00 p.m.
*At the start of her shift that day she noted two unlabeled syringes with liquid in them on top of the medication cart.
*LPN S was the nurse who worked the previous shift, and she was not at the medication cart at that time.
*When RN E completed the narcotic count with LPN S they noted there were discrepancies to the count for resident 4's oxycodone and lorazepam medications.
*She requested LPN S correct the narcotic record.
*LPN S left that day without correcting the narcotic record.
*RN E notified DON A of the narcotic record counts being off the evening of 2/5/25.
*RN E had received education since the 2/5/25 incident occurred from the providers pharmacy regarding controlled substances and correct documentation.
Interview on 5/29/25 at 5:20 p.m. with DON A revealed:
*LPN S was terminated on 2/6/25 after the provider's investigation into the controlled counts for resident 4 was completed.
*The providers pharmacy completed staff education regarding narcotics and documentation with nursing staff.
*Audits were completed and documented signed out in MAR, signed out on narcotic receipt/record/disposition form, and narcotic counts are correct.
-Audits were completed on all units.
-completed at least twice weekly.
The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 5/29/25 after a record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding medication administration and diversion education, interviews revealed that staff understood the education provided regarding those topics, review of narcotic records for three of the four wings revealed with no further missing documentation of narcotic records for current residents, and a review of providers Controlled substances policy dated 2/25 confirmed processes for accountability of controlled medications.
Based on the above information, non-compliance at F658 occurred on 2/5/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 5/29/25, the non-compliance is considered past non-compliance.
Nov 2024
6 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Food Safety
(Tag F0812)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to:
*Ensure that staff were able to veri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to:
*Ensure that staff were able to verify the chemical sanitation level required to clean the main kitchen surfaces used for the preparation of residents' food. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the main kitchen.
*Maintain the dishwasher sanitation rinse cycle temperature at a minimum of 180 degrees Fahrenheit per the manufacturer's manual for two of four kitchenette dishwashers. Failure to ensure that increased the potential risk of foodborne illnesses for 27 of 27 residents (1, 3, 14, 17, 18, 21, 23, 24, 25, 26, 27, 31, 34, 35, 36, 38, 39, 40, 41, 42, 44, 46, 47, 48, 49, 50, and 52) who received meals on dishware cleaned in those two kitchenettes.
Findings include:
1. Observation and interview on 11/5/24 at 11:41 a.m. during the initial tour of the main kitchen revealed:
*There was a metal cart with visibly soiled dishes in the entryway to the kitchen located between the door and the dishwasher.
*The floor below the sink was wet.
*A pan marked beef for stroganoff on the counter.
*Dietary director (DD) E stated she started in her position two months ago.
-She indicated there had been a huge staff turnover.
*DD E stated that the residents' food prepared for lunch had already been delivered to the neighborhoods.
-Lunch was served starting at 11:30 a.m.
*The beverage dispensing machine was taken apart and cleaned.
*A red sani-bucket was on a metal cart that contained liquid and a cloth.
*The sanitizer strip test kit was labeled expired September 2024.
*The Diversey chlorine test strips were labeled exp May 15, 2024.
*A dishwasher wash and rinse log on the wall had recorded temperatures for breakfast, lunch, and dinner on 11/2/24.
-No dishwasher wash or rinse temperatures had been recorded on 11/1/24, 11/3/24, 11/4/24 or 11/5/24.
Interview on 11/5/24 at 12:11 p.m. with dietary aide S in the main kitchen revealed:
*The sanitizer test strips were used for testing the contents in the 3-compartment wash sink and the sanitizer buckets.
-They were the only test strips in the kitchen.
*There was no log documenting when the strips had been used.
*All dishes used in the main kitchen were put through the dishwasher.
-It was a high-temperature dishwasher.
*There was a log to record the dishwasher temperatures for the washing of the dishes used with each meal service.
-The dishes for lunch had not been washed yet that day.
Observation and interview on 11/6/24 at 10:45 a.m. in the main kitchen with cook T revealed:
*She used a cloth from the red sani-bucket to wipe the counter where she had prepared fried food.
*She rinsed the cloth in the red bucket and continued to wipe the surfaces of the items on the counter with that cloth.
*She stated the bucket was filled every two hours or more often when dirty.
*She stated she keeps track of her bucket and changes it at least every 2 hours but usually more often when she used it.
*She confirmed there was no log or sticker on the bucket that indicated when it had been last changed or tested.
*The sanitizer in the bucket was a chemical solution filled from the hose at the 3-part sink.
*She stated, They [sani-buckets] are tested every so often.
-She was unsure how often the sanitizer was tested.
-She stated she did not do the testing.
*She confirmed that it was not tested each time the bucket was filled to ensure proper sanitization.
Observation and interview at 11/6/24 at 10:50 a.m. with DD E in the main kitchen revealed she:
*Confirmed they did not have a system to test the solution in the sani-buckets to ensure the sanitizer was at the appropriate level or a method to document the testing results.
*Confirmed the chlorine test strips were expired.
-She stated, But that's ok because we don't use them anyway.
*Stated, They [staff] weren't doing it [using the chlorine test strips] when I started.
*Was unsure what the facility policy was but stated I will find out.
*Confirmed that the solution was J-512 Sanitizer and stated it was a preset system so we do not have to test.
*Confirmed the dishwasher was a high-temperature dishwasher.
*A dishwasher log was posted on the wall.
-The dishwasher log had rinse temperatures recorded over 180 degrees for 11/5/24 and 11/6/24.
Observation and interview on 11/6/24 at 11:22 a.m. in the [NAME] Creek kitchenette with DD E revealed she:
*Transported the food from the main kitchen to the [NAME] Creek kitchenette.
*Obtained dishes from the cabinet in that kitchenette.
*Confirmed that those dishes were washed and sanitized in the dishwasher in the kitchenette.
-Confirmed each neighborhood washed its own plates, cups, bowls, and utensils that were used for serving the residents food items.
Observation and interview on 11/6/24 at 12:09 p.m. in the [NAME] Creek dish room with CMA J revealed:
*The nursing staff was responsible for washing and sanitizing the dishes in each neighborhood.
*She pre-washed the dishes in the sink and loaded them into the dishwasher.
*She ran the dishwasher cycle.
-The wash temperature reached 165 degrees and the rinse temperature reached 183 degrees.
*She stated she did not log or record any dishwasher wash or rinse temperatures.
*She stated, If that's [logging of temperatures] done it would be maintenance.
*She confirmed there was no dishwasher log located in the kitchenette.
Interview on 11/6/24 at 3:37 p.m. with Administrator (Admin) A revealed:
*There were no cleaning logs for the kitchen or kitchenettes.
*He expected nursing staff to wash the dishes, to mop the floor, and to keep the area clean.
*The neighborhood kitchenettes had not used the sani-bucket.
-The cleaner on the kitchenette was the Q 3 disinfectant spray.
*He confirmed that in the main kitchen, they used the sani-bucket.
*He confirmed that they should be testing the PPM [parts per million of the sanitizer solution] for the sanitizer buckets to ensure the sanitizer was at an appropriate level.
-He confirmed there was no record that the sanitizer had been tested.
*He was not aware that the sanitizer test strips were expired.
Interview on 11/6/24 at 4:30 p.m. with Admin A revealed:
*The provider did not have a Dishwasher/Sanitation policy.
*He stated we go by the manufacturer's book.
*The provider did not have a Household/neighborhood kitchenette cleaning policy or logs.
*The provider did not have a Kitchen equipment sanitizing/cleaning policy or logs.
*Maintenance would have had kitchenette dishwasher temperature logs because they oversaw the kitchenette dishwashers.
Interview and review of kitchenette dishwasher logs and dishwasher manufacturer specification on 11/06/24 at 4:31 p.m. with campus environmental service director (CESD) D revealed:
*He provided a copy of the [NAME] Model LXIH-4 LHi Dishmachine specifications which included the following:
-RINSE AND SANITATION: LXIH: Sanitation is accomplished by means of a built-in booster heater designated to raise temperature of water to a minimum of 180 degrees Fahrenheit from an incoming water temperature of 110 degrees Fahrenheit.
*This was the information used when determining the correct dishwasher temperatures.
*Neighborhood kitchenette dishwasher temperature logs were completed and kept by maintenance.
-Dishwasher temperatures were monitored and logged on each of the four neighborhoods about once every three weeks by maintenance.
-He was not aware if any other staff monitored those dishwasher temperatures.
*He kept the recorded temperatures in a notebook.
*The dishwasher temperatures were checked and logged on 8/5/24, 8/19/24, 8/28/24, 9/15/24, 10/7/24, and 10/28/24.
-All of those wash temperatures were recorded between 154-164 degrees Fahrenheit.
-All of those rinse temperatures were recorded between 180-186 degrees Fahrenheit.
Interview on 11/7/24 at 7:45 a.m. with Admin A revealed:
*He provided the survey team with a Kitchen Sanitation Policy dated 11/2024.
-He confirmed this policy included the main kitchen and the kitchenettes.
*He provided the survey team with a Sanitizer Preparation Policy dated 01/2024.
*He confirmed they did not have a separate dishwashing policy and referred to the manufacturer information previously provided.
*He stated the dietitian would be at the facility today 11/7/24.
Observation and interview on 11/7/24 at 8:12 a.m. with consulting registered dietitian (CRD) H in the main kitchen revealed she:
*Visited the facility once a week on Thursdays.
*Documented her visits with individual residents in their charts.
*Checks-in with DD E when she visited.
-She did not document those check-ins.
-They also communicated through email.
*Was not conducting any current audits in the kitchen.
-Was unable to recall if she had completed any audits recently, I would have to check my email.
-Confirmed there were no written audits completed.
*Stated, There is a cleaning schedule for the kitchen.
-Stated she would provide a copy of that cleaning schedule to the survey team.
--A cleaning schedule was not provided by the end of the survey.
*Was not familiar with the procedures of sanitizing in the kitchen and agreed that we should include DD E in the interview.
Continued observation and interview on 11/7/24 at 8:18 a.m. with CRD H and DD E in the main kitchen revealed:
*DD E demonstrated the use of the sani-bucket.
-She confirmed the new test strips were not expired.
-There was a new log sheet for recording when the sanitizer solution was filled or tested.
-She confirmed that the sanitization level in the sani-bucket was 200 PPM.
-That had been documented on the log in the kitchen when it had been filled that morning.
*DD E confirmed the main kitchen dishwasher temperatures were logged with each meal service three times a day.
*DD E was unsure if there was a policy on the frequency of checking the dishwasher temperatures.
*DD E confirmed that the dishes used by the residents including plates, bowls, cups, and utensils were washed and sanitized in each of the four neighborhoods.
*DD E was unsure how frequently the neighborhood dishwasher wash and rinse temperatures should have been monitored.
*CRD H stated she expected it would have been the same frequency as the main kitchen.
*DD E stated that maintenance oversees the neighborhood kitchenettes, and any dishwasher temperature logs could be requested from that department.
-CRD H and DD E were not aware of what frequency maintenance checked the kitchenette dishwasher temperatures.
*When asked how they could ensure that dishes were sanitized in the neighborhood kitchenettes, DD E stated, I couldn't.
*CRD H and DD E were not familiar with the procedures of sanitizing dishes in the neighborhood kitchenettes and agreed that we should include maintenance in the interview.
Observation and interview on 11/7/24 at 8:39 a.m. in the [NAME] Way kitchenette with CRD H, DD E, CESD D, and maintenance staff U revealed:
*A sign on the dishwasher indicated This is a sanitizer. Not a dishwasher.
-Maintenance staff U confirmed that the machine is both a dishwasher and a sanitizer and the sign was inaccurate.
-She stated that the dishes are prewashed before putting them in the machine to reduce the food particles in the machines.
*Maintenance staff was responsible for overseeing the dishwashers for proper functioning in the kitchenettes.
*The dishwasher had an E7 code displayed.
-Maintenance staff U stated the code indicated the dishwasher was out of soap.
--She changed the soap and reset the machine.
*Maintenance staff U stated she checked the dishwashers Every day I am here.
-She did not keep a log or record those checks.
-She stated she looked at the temperature on the digital display of the dishwasher and as long as it is 150 or above it's good.
-When the temperature was below 150 degrees Fahrenheit, she would reset the machine.
-There was no need to run the dishwasher through a cycle to check the rinse temperature during those checks, because it's always hot enough.
*Maintenance staff U ran the dishwasher.
-On the first cycle the wash temperature reached 164 degrees Fahrenheit, and the rinse temperature reached 180 degrees Fahrenheit.
*Maintenance staff U stated she expected staff to alert her right away if there were any problems with the dishwashers.
Observation and interview on 11/7/24 at 8:52 a.m. in the Cottonwood Court kitchenette with CRD H, DD E, CESD D, and maintenance staff U revealed:
*Maintenance staff U ran the dishwasher.
*On the first cycle the wash temperature reached 165 degrees Fahrenheit, and the rinse temperature reached 177 degrees Fahrenheit.
*A sign in the kitchenette indicated that plates, bowls, and cups were to be sanitized twice and utensils were to be sanitized three times.
*On the second cycle the wash temperature reached 165 degrees Fahrenheit, and the rinse temperature reached 177 degrees Fahrenheit.
*On the third cycle the wash temperature reached 162 degrees Fahrenheit, and the rinse temperature reached 174 degrees Fahrenheit.
-Those temperatures were confirmed by maintenance staff U, CRD H, DD E, and CESD D.
*A copy of the posted sign was requested in the absence of a policy and was not provided by the end of the survey.
*CESD D confirmed the last time the kitchenette dishwasher temperatures were checked and recorded was on 10/28/2024.
Observation and interview on 11/7/24 at 8:58 a.m. in the Maple Valley kitchenette with CRD H, DD E, CESD D, and maintenance staff U revealed:
*Maintenance staff U ran the dishwasher.
*On the first cycle the wash temperature reached 160 degrees Fahrenheit, and the rinse temperature reached 179 degrees Fahrenheit.
*On the second cycle the wash temperature reached 166 degrees Fahrenheit, and the rinse temperature reached 179 degrees Fahrenheit.
*On the third cycle the wash temperature reached 167 degrees Fahrenheit, and the rinse temperature reached 177 degrees Fahrenheit.
-Those temperatures were confirmed by maintenance staff U.
Observation on 11/7/24 at 9:15 a.m. of maintenance U revealed she walked from Cottonwood Court through the common area outside of the conference room carrying what appeared to be a cordless drill/screwdriver.
Interview on 11/7/24 at approximately 10:00 a.m. with Admin A regarding the dishwasher temperatures revealed:
*He requested that the surveyor return to recheck the temperatures of the dishwasher.
*He stated the dishwashers had been calibrated and had temped them and they were at the correct temperature.
Interview on 11/7/24 at 9:45 a.m. with CRD H revealed:
*She provided the survey team with a 2013 [NAME] & Associates Sanitation of Dishes/Dish Machine policy.
-This policy had not been provided earlier.
*She stated that this was the regulation that they followed regarding dishwasher temperatures.
Review of the 2013 [NAME] & Associates Sanitation of Dishes/Dish Machine policy revealed:
*High Temperature Dishwasher Wash Temperature 150-160 degrees Fahrenheit, Final Rinse Temperature or Sanitization 180 degrees Fahrenheit.
Notice:
On 11/7/24 at 8:58 a.m., immediate jeopardy was identified related to failure to maintain the manufacturer's specification for the dishwashers' rinse cycle temperatures of a minimum of 180 degrees Fahrenheit at F812.
Notice of immediate jeopardy was given verbally and in writing on 11/7/24 at 11:55 a.m. to Admin A and director of nursing B of the immediate jeopardy related to failure to maintain the manufacturer's specification for dishwasher rinse cycle temperatures of a minimum of 180 degrees Fahrenheit at F812. They were asked for an immediate removal plan. The current resident census was 52.
Interview on 11/7/24 at 1:18 p.m. with Admin A and the survey team coordinator revealed:
*He requested to speak with the survey team coordinator.
*He stated he felt like this was certainly tag worthy but from an immediate jeopardy perspective I feel like that is incredibly out of proportion.
*He stated, Within five minutes of that temperature being off, it was corrected.
*He stated, I would completely understand a tag associated with that, and for corrective action and for not documenting it.
*He stated he understood the deficiency was warranted but was concerned with the repercussions from an IJ severity deficiency.
*The survey team coordinator asked about the IJ removal plan and stated the team needed to review the provider's IJ removal plan to continue with the process.
On 11/7/24:
*At 1:31 p.m. the removal was received.
*At 2:17 p.m. the removal was accepted.
On 11/7/24:
*At 4:06 p.m. while on-site the survey team verified the immediacy was removed.
Plan:
Survey 11/07/2024 Removal Plan
After evaluation and meeting with the survey team, the recipients who could have suffered from this situation are the residents at [NAME] Home [NAME] on Maple Valley and Cottonwood Court as those were the neighborhoods that had temperature readings below 180 degrees.
Neighborhood Dish Machine POC [plan of correction]:
On 11/07/2024, the Environmental Services Director calibrated the dish machines on all neighborhoods to increase the temperature of the rinse cycle. Both dish machines on Cottonwood Court and Maple Valley did reach the required temperature of 180 degrees before recalibration. All rinse cycles reached at least 180 degrees F [Fahrenheit] after changes made.
Beginning 11/07/2024, a dish machine temperature log was implemented on all neighborhood dish machines.
IDT [interdisciplinary team] reviewed and revised the policy and procedures related to dish machine temperature logs and the sanitation of dishes/dish machines on 11/07/2024.
Beginning 11/07/2024, all staff responsible for using the neighborhood dish machines will be educated on the policies and procedures related to the dish machine temperature log and the sanitation of dishes/dish machines. All nursing and dietary staff will be educated on this policy by 11/15/2024 via personal in-service. [Admin A initials] 11/07/2024.
Beginning 11/07/2024, all staff responsible for using the neighborhood dish machines will be educated that if the dish machines do not reach 180 degrees F, they are to contact the Environmental Services Director.
Beginning 11/07/2024, the Dietary Director, or designee, will audit the dish machine temperature logs. Audits will be daily for four weeks and weekly for two more months.
The Dietary Director or designee will present the findings of the audit to the QAPI [Quality Assurance and Performance improvement] committee at their quarterly meeting for review and recommendation.
The immediate jeopardy was removed on 11/7/24 at 4:06 p.m. after verification that the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was F with guidance from the long-term care advisor for the South Dakota Department of Health.
The current resident census was 52.
Review of the provider's November 2024 Kitchen Sanitation Policy revealed:
*Purpose: To establish responsibilities for maintaining a clean and sanitary kitchen environment.
*Responsibilities:
-Dietary Director
--Establish and maintain sanitary standards of cleanliness and food handling practices.
--Ensure proper maintenance, operation and cleaning of all equipment.
-Environmental Services:
-- Preventative maintenance will be performed on equipment in the Nutrition Service Department.
*Equipment Maintenance:
-All equipment used by Nutrition Services meets standards of the State Department of Health
-The dishwasher is maintained and operated according to manufacturer's instructions. Hot water dish machines need to run at at 155 degrees for wash cycle and minimum of 180 degrees for rinse cycle.
-Temperature/appropriate sanitation levels are checked & recorded daily.
-All work surfaces and utensils are cleaned and sanitized after each use.
-Cleaning schedules are posted & include frequency, position responsible & off when completed.
Review of the provider's January 2024 Sanitizer Preparation Policy revealed:
*Purpose: Established the procedure to test sanitation solution for surface cleaning.
*Prepare the sanitizer bucket according to the manufacturer's recommendation.
*Check expiration date on test strip canister to ensure they are not expired.
*Log what results are given by the test strip.
2. Observation on 11/6/24 at 11:30 a.m. of resident 25 being served lunch revealed:
*Hospice certified nursing assistant (CNA) V assisted her to eat a sandwich.
-She assisted with her bare hands giving her bites off the sandwich.
-She then began cutting the sandwich with a fork and fed her bites from the fork but went back to handling the sandwich with her bare hands.
Interview on 11/6/24 at with CNA V revealed she did not use gloves when she assisted residents to eat. She stated she would wash her hands or use hand sanitizer.
Interview on 11/06/24 at 2:35 p.m. with director of nursing (DON) B revealed that CNA V should have worn gloves when handling the ready to serve sandwich. She stated she would have had the same training as her CNAs for handling ready to serve foods.
Interview on 11/6/24 at 3:00 p.m. with DON B regarding orientation of a Hospice nursing assistant revealed they would shadow with one of her CNAs for one day. She did not have anything in writing or have them sign anything.
Interview on 11/08/24 at 11:57 p.m. with CNA V revealed:
*She stopped this surveyor in the hall and stated, I should have worn gloves when handling resident 25's sandwich, I can't believe I did that. she stated she had more training yesterday 11/7/24.
Review of the provider's General Food Preparation and Handling policy dated 1/1/24 revealed, 5. Equipment f. Use tongs or other serving utensils to serve breads or other items. Never touch food directly with bare hands.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) complaint, interview and policy review the provider failed to thoroughly inv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) complaint, interview and policy review the provider failed to thoroughly investigate an incident of an alleged certified nursing assistant being intoxicated while at work and allowed her to work the weekend following the incident.
Findings include:
1. Review of the SD complaint report dated 5/7/24 revealed:
*The complainant wished to remain anonymous.
*She was terminated Monday 4/29/24 for suspected intoxication.
*She worked an evening shift on Friday 4/26/24 but usually worked day shifts.
*A beverage container had been found that smelled like alcohol in the staff break room.
*Police were contacted and had no concerns about her being intoxicated and let her go home.
*She worked the next two days Saturday 4/27/24 and Sunday 4/28/24 without follow up from the administration.
*She had not been the one to use alcohol and the residents were still at risk and the facility needed to continue their investigation.
*She did not want her job back and had worked at the facility for five months.
2. Interview on 11/05/24 at 1:46 p.m. with resident 1 revealed:
*She is sitting in her wheelchair in her room.
*She stated things are going well here and was headed to worship and study but could talk later.
*She stated a female on night shift doesn't seem to get her brief on straight, otherwise no problems with any staff, and she was not aware of staff by name of CNA N.
3. Interview on 11/06/24 at 11:06 a.m. with resident 1 revealed:
*She had broken her leg back in March when she fell in the bathroom and could transfer herself at that time.
*She did pivot transfers with staff help now and had not had any injuries since the fall.
*She stated she heard her left shoulder crackle a couple of time when she had been assisted. I had that replaced quite a while ago.
-She stated she is doing therapy and would see her doctor about her shoulder.
4. Interview on 11/07/24 at 4:39 p.m. with resident 1 revealed she does not use a mechanical lift, she stated, she did that one-foot turn [pivot transfer] with help and had no injuries or complaints about staff.
5. Interview on 11/08/24 at 10:46 a.m. with CNA O revealed she worked morning shifts and had never seen or heard of any staff or coworker working under the influence of alcohol. She had not seen or heard of any alcohol being in the facility staff break room. She stated if she had seen or seen that she would report that to administration.
6. Interview on 11/8/24 at 10:48 a.m. with licensed practical nurse (LPN) P revealed she was not aware that anyone had worked under the influence of alcohol, or that any alcohol had been in the breakroom but would report it if she had.
7. Interview on 11/8/24 at 3:00 p.m. with director of nursing (DON) B revealed:
*She had an incident with a staff member that was suspected of being intoxicated when she had worked 4/26/24.
-She stated that she was certified nursing assistant (CNA) Q and had picked up that 6-10 p.m. evening shift.
-She stated staff had called her around 9:45 p.m. stating that CNA Q was acting strange and that they smelled alcohol on her breath while completing cares.
-She stated she had them call the police, but [NAME] had left the facility.
-She stated she received report from her staff that the police had stopped CNA Q in the parking lot but a breathalyzer had not been done because the police did not think she was intoxicated as she was not stumbling when she walked and allowed her to go home.
-She stated a tumbler was found in the break room that smelled like there was alcohol in it.
-DON B stated that CAN Q did not work the weekend and was not on the schedule.
-She stated she would get the staff schedule for that weekend.
8. Interview and review of staff schedules on 11/8/24 at 3:13 p.m. with DON B revealed:
*She stated CNA Q was on the schedule and worked Saturday 4/27/24 and Sunday 4/28/24 following the incident that happened Friday 4/26/24.
*Staff schedule indicated CNA Q had worked 6:00 a.m. to 2:00 p.m. that weekend.
*She stated, That was a long time ago, I couldn't remember she had worked.
-She stated, The police did not think she was intoxicated CNA Q was allowed to work.
-She stated she had asked her staff questions regarding the incident on the phone but she did not further investigate the incident.
-She had not come into the facility the night of the incident because CNA Q would have been gone by the time she would have gotten there.
-She came in 4/29/24 Monday morning and that was when she smelled the container with the alleged alcohol in it.
-She stated CNA Q was terminated 4/29/24.
9. Review of personnel consultation Termination record dated 4/29/24 revealed:
* Name: CNA Q.
- Category: Termination.
- Subject: Drinking on the Job.
- On 4/26/24 it was reported by other staff working that night that you smelled of alcohol and were behaving strangely.
-The charge nurse approached you and informed you that you would be subject to a breathalyzer to ensure that you hand not been drinking. You then left the facility and were stopped by the police who offered you a breathalyzer to show you had not been drinking and you declined, and they had no reason to suspect that you had been drinking.
- On 4/29/24, [NAME] Administration found a cup that is believed to belong to you and it contained a liquid that smelled of alcohol.
- As a result of these finding, [NAME] will immediately be terminating your employment.
- Employee signature indicated, Employee terminated via phone, initialed by administrator A 4/29/24.
- Employee Comments had been left blank.
- Signed by human resource manager M.
- Signed by department supervisor DON B and administrator A.
- This form may be used for all types of counseling including warning records and disciplinary action records.
10. Review of SD Department of Health Facility report incident revealed:
*Administrator A handed this surveyor that report and stated, This is the investigation that was done.
- Patient/Resident name indicated resident 1 on the report.
- Cognition score was fifteen [indicated her cognition was intact].
-The report was completed and signed by administrator A.
- Date and Time of Event, 4/26/24 at 8:00 p.m.
- Type of Event Being Reported, Suspicion/allegation of abuse/neglect.
- Allegation type, Other, Suspected intoxicated employee.
- Law enforcement was notified for suspected intoxication.
- Law enforcement was notified 4/26/24 at 9:45 p.m.
- APS worker was notified by an emailed report for suspected resident neglect on 4/29/24 at 4:20 p.m.
- Health Department was notified on 4/20/24 at 4:20 p.m.
- Investigation Conclusion: Conclusionary summary statement of facility investigation: (Please include all specific interventions put in place to prevent further occurrences. There was no information provided.
- Suspicion/Allegation of Abuse/Neglect: Facility personnel.
- Is the individual capable of providing an explanation of the event or capable of participating in investigation? Yes.
- Provide a brief explanation of event being reported. Please include name(s) of Patient/Resident/Personnel/Family/Visitors involved with event: On 4/26/24 it was reported to the Director of Nursing that CNA Q, smelt of alcohol and that she was acting weird and disappearing for long stretches of time. Facility called the police and requested that they give the staff member a breathalyzer test. Staff member refused to be tested and left the facility. A water bottle tumbler was then found on her neighborhood that had pink liquid in it that smelled strongly of alcohol. By leaving without submitting to a breathalyzer, CNA Q violated [NAME] policy and was terminated on the afternoon of 4/29/24.
- Interview with CNA/Med Aide N: CMA N was assisting CNA Q with cares with the above resident and stated that CNA Q was discussing problems with her boyfriend with the resident. At that time CMA N said she was acting weird and was thinking hard about what she was going to say before she spoke. CNA Q then asked CMA N for help assisting the above listed resident. During cares for the above listed resident CNA N said CAN Q smelled of alcohol and that CNA Q was having hard time completing the cares for the resident. CMA N stated he never saw her drinking any liquids that night and did not see CNA Q drinking from the cup that was later found to have alcohol in it. CMA N told the nurse on duty who call the DON B. CMA N said the nurse on duty told CNA Q she would need to be breathalyzed at which time CNA Q left the facility.
- Interview with licensed practical nurse (LPN) R: LPN r stated that both her and CAN Q arrived to work at 6:00 p.m. at which time LPN R started passing pills on Maple Valley. LPN R stated she got to Cottonwood Court around 8:15 p.m. She saw CNA Q in the dish room talking on her phone and that CNA Q ran into the door frame of the dish room when she came back out. CMA N approached LPN R at about 9:00 p.m. and said that CNA Q smelled like alcohol. LPN R texted DON B. During this time, LPN R stated that CNA Q would disappear off the unit for extended periods of time and they would find her in random resident rooms. LPN also stated that CNA Q was very anxious and having a hard time speaking during the shift. At 9:45 p.m. LPN R informed CNA Q that the police were on their way and that she would be subjected to a mandatory breathalyzer to which CNA Q seemed nervous and said that is suspicious. LPN R went to go assess a resident and when she came back CNA Q was gone. LPN R went to the front entrance of the facility and saw CNA Q with the police. After LPN R returned to the neighborhood, she found the green tumbler at which point she opened the container and smelled it and it smelled strongly of alcohol. CNA Q refused a breathalyzer from the police and left the facility. Police informed Administrator A and DON B that they could not pursue any charges against her as they had no evidence that a crime had been committed. CNA Q was terminated effective 4/29/24.
*'Substantiation and Action: Was abuse/neglect allegations substantiated: No, why or why not? Unable to completely substantiate but evidence presented made it clear that CNA Q needed to be terminated.
- If a patient/resident was suspected of abuse/neglect, was it a willful act? Yes.
- Action taken by the facility; Personnel terminated.
11. Review of [NAME] Homes/Meadows/Foundation 2024 Employee handbook revealed:
*Drug Testing on page 33:
- [NAME] has adopted screening and testing practices to identify employees who use illegal drugs on or off the job, and to identify employees under the influence of alcohol on the job. Refusal to submit to drug or alcohol testing being conducted by the facility will be considered a positive test. Such refusal may lead to disciplinary action, up to and including immediate termination.
* Purpose: In compliance with the Drug-Free Workplace Act of 1988, [NAME] has a longstanding commitment to provide a safe, quality-oriented, and productive work environment consistent with the standards of the community in which [NAME] operates. Alcohol and drug abuse poses a threat to the health and safety of [NAME] employees, residents, family, and guests. For these reasons, [NAME] is committed to the elimination of drug and alcohol use and abuse in the workplace.
*Work Rules:
- 1. Whenever employees are working, are present on [NAME] premises or are conducting company-related work offsite, that are prohibited from:
- b. Being under the influence of alcohol, or an illegal drug as define in this policy.
- c. Possessing or consuming alcohol.
* Page 35 Reasonable suspicion:
- Employees are subject to testing based on (but not limited to) observations by the supervision of apparent workplace use, possession, or impairment. HR [human resources], the supervisor or Administration are to be consulted before sending an employee for testing. Under no circumstances will the employee be allowed to drive himself or herself to the testing facility. A member of supervision/management must escort the employee or arrange for a safe driver, the supervisor/ manager will make arrangements for the employee to be transported home. The expense of this arrangement will be the responsibility of the employee.
* Follow-up:
- Employees who have tested positive, or otherwise violate this policy, are subject to discipline, up to and including discharge from employment. At management discretion depending on the circumstances and the employee's work history/record, [NAME] may offer an employee who violates this policy or test positive one time the opportunity to return to work on a last-chance basis pursuant to mutually agreeable terms, which could include follow-up drug testing at times and frequency determined by [NAME] for a minimum of one year. If the employee either does no complete the rehabilitation program ort tests positive after completing the rehabilitation program, the employee will be subject to immediate discharge from employment.
*Consequences:
- Employees who refuse to cooperate in required test or who use, possess, buy, sell manufacture or dispense an illegal drug in violation of this policy will be terminated. If the employee refuses to be tested, yet the company believe he or she is impaired, under no circumstances will the employee be allowed to drive himself or herself home. Refusal to cooperate will result in a call to the police.
- Page 36, The first time an employee tests positive for alcohol or illegal drug use under this policy, the result will be discipline up to and including discharge.
- Employees will be paid for time spent in alcohol or drug testing and then suspended without pay pending the results of the drug or alcohol test.
*Page 58, Discipline Procedures:
- 3. Suspension: Suspension is a form of discipline normally reserved for severe infractions of rules, standards, or for excessive violations for which the employee has already received a written warning and the employee has made insufficient effort to improve performance or behavior. However, an employee can be placed on paid or unpaid suspension for disciplinary reasons, for example; excessive absenteeism, medication errors, or an incident requiring investigation such as, abuse, or the results of drug testing.'
- 4. Termination: [NAME] may accelerate or omit any of the steps mentioned above.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the Centers for Medicaid and Medicare (CMS) Resident Assessment Instrument (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the Centers for Medicaid and Medicare (CMS) Resident Assessment Instrument (RAI) Manual review, the provider failed to ensure the Minimum Data Set (MDS) assessments were coded accurately for two of two residents (23 and 32) who had a seat belt in their wheelchairs. Findings include:
1.Observation and interview on 11/5/24 at 2:04 p.m. with resident 23 revealed:
*She was in her room in an electric wheel chair and had a seat belt on.
*She stated she could do most things for herself from her waist up.
*She would do crafts and sew in her room and would help with seasonal decorating of the facility.
Review of resident 23's electronic medical record revealed (EMR):
*Her Brief Interview of Mental Status (BIMS) assessment dated [DATE] had a score of fifteen which indicated her cognition was intact.
*Her MDS dated [DATE] indicated:
-Trunk restraint was coded as not used in the chair or the bed.
-Other was coded as Used daily.
-An edit note, Resident uses a seat belt on her electric wheelchair. She utilizes this per her choice. She ss able to don [put on] after set up, and doff [remove] this independently. This is reassessed quarterly.
*She had a restraint assessment completed on 10/21/24 for the use of the seat belt on her power wheelchair that indicated she could release it herself and felt safer with this on.
*Her care plan dated 2/1/22 indicated she requested the seat belt for safety and could apply it and remove it herself.
*That care plan also included Perform restraint assessments quarterly and as needed due to the use of my seatbelt in my electronic wheelchair.
2. Observation and interview on 11/05/24 at 2:26 p.m. with resident 32 revealed she:
*Had limited movement of the right arm and hand.
*Was seated in a wheelchair with a forward-leaning posture.
-The wheelchair had a seat belt that was not fastened.
--The seat belt straps hung in front of the brakes on each side of the wheelchair.
*Stated she had several falls that led to her admission to the facility, but I've been more careful and haven't fallen recently.
*Stated she wasn't sure what the seat belt was for and did not know if she could remove it on her own because she was not wearing it.
*Was easily distracted and changed the subject frequently.
Observation and interview on 11/08/24 at 9:15 a.m. with resident 32 revealed she:
*Was seated in her wheelchair and the seat belt straps hung in front of the brakes on each side of the wheelchair.
*Was easily distracted and unable to demonstrate that she could put on or remove the seatbelt.
*Stated, I don't know what is going on today.
Review of resident 32's EMR revealed:
*She was admitted on [DATE].
*Her 10/31/24 Brief Interview for Mental Status (BIMS) assessment score was 9, which indicated she was moderately cognitively impaired.
*Her care plan included an intervention initiated on 2/5/24, OT [occupational therapy] has put a seat belt on my wheelchair to help with positioning. I am able to put it on and remove it on my own.
*Her care plan included an intervention initiated on 4/8/24, I have dycem [a non slip mat] in my wheelchair and have received verbal education on the importance of using the seatbelt in my wheelchair that OT previously provided. I am able to apply and remove this myself.
*An 11/4/24 Restraint Assessment that indicated:
-The Type of restraint considered for use: seat belt.
-Reason restraint is considered: (describe) wheelchair positioning.
-During what time of day would it be used? When resident is up in wheelchair.
-How long each day? Anytime in w/c [wheelchair].
-What is the resident/family wishes or attitude related to restraint use? Family and resident ok with safety belt.
Review of resident 32's 10/31/24 quarterly MDS assessment, section P (Restraints and Alarms) revealed:
*Trunk restraint was coded as not used in the chair or the bed.
*Other was coded as Used less than daily.
*An edit note, resident has a seatbelt that she is able to remove herself. However, she rarely uses it.
3. Interview on 11/08/24 at 10:34 a.m. with director of nursing (DON) B revealed:
*She confirmed two residents in the facility used seat belts.
*Resident 23 had a seatbelt as a safety device that she used daily.
*Resident 32 had a seat belt for safety, that she rarely used.
*She stated, They are not being used as a restraint.
*She assisted with the completion of the MDS assessments.
-She confirmed the seatbelts were coded on the MDS as restraints.
Review of the October 2023 CMS RAI Version 3.0 Manual Section P, Page P-6 revealed:
*Trunk restraints include any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot easily remove such as, but not limited to, vest or waist restraints or belts used in a wheelchair that either restricts freedom of movement or access to their body.
Review of the providers' revised 1/1/24 Physical Restraint Policy and Procedure to be Least Restrictive policy revealed:
*Physical restraints are any method or physical or mechanical device, material, or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement for normal access to one's body; this includes . wheelchair belts . that cannot be released easily by their resident .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the provider failed to:
*Ensure privacy had been maintained during interviews conducted in r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the provider failed to:
*Ensure privacy had been maintained during interviews conducted in resident rooms for 13 of 13 (2, 13, 19, 21, 22, 27, 28, 41, 47, 48, 49, 52, and 106) residents with audio and video monitoring devices in their rooms.
*Obtain consent for audio and video monitoring use for 6 of 13 (13, 41, 47, 49, 52, and 106) residents with audio and video monitoring devices in their rooms.
Findings include:
1. Observation and interview on 11/05/24 at 1:27 p.m. with resident 28 in his room revealed:
*An iFamily audio/video camera was on top of his closet facing his recliner.
*He was unable to identify the audio/video device in his room.
-He was conversive but unable to answer questions about the audio/video monitoring device.
*There was no sign at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room.
2. Observation and interview on 11/05/24 at 2:22 p.m. and again on 11/08/24 at 8:36 a.m. with resident 22 in his room revealed:
*An iFamily audio/video camera was on the bedside table next to the lamp.
*He was unable to identify the audio/video device in the room.
*An Echo Dot device [a smart speaker with an internet connection and a drop-in feature that allows instant connection between connected devices] was located between 2 recliners.
*There was no sign at the entrance to the room or within the room that indicated audio/video monitoring devices were used in that room.
3. Observation and interview on 11/05/24 at 2:36 p.m. with resident 13 in his room revealed:
*An iFamily audio/video camera was located on his nightstand.
*He was unable to identify the audio/video device.
-I don't know what that is.
*There was no sign at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room.
Review of resident 13's electronic medical record revealed (EMR):
*There was no documentation that resident or family consent was obtained for the use of the audio/video monitoring device.
*There was no documentation that the care plan had been updated to reflect the use of the audio/video monitoring device.
4. Observation and interview on 11/05/24 at 3:18 p.m. with certified nursing assistant (CNA) L in resident 106's room revealed:
-CNA L sat on resident 106's bed visiting with her because she keeps trying to get up and walk.
*A white monitoring device was on the windowsill.
-CNA L stated that it was an audio-only device.
*CNA L confirmed that other devices in the facility had video cameras, but this one did not.
*There was no sign at the entrance to the room or within the room that indicated an audio monitoring device was used in that room.
Review of resident 106's EMR:
*There was no indication that resident or family consent was provided for the use of the audio device.
*There was no indication that the care plan had been updated for the use of the audio device.
Observation on 11/6/24 at 8:19 a.m. of resident 106's room revealed that the audio monitoring device was no longer present in that room.
5. Observation and interview on 11/05/24 at 3:29 p.m. with resident 19 in his room revealed:
*He had an Echo Dot device he called [NAME] in his room.
-His son had helped him set it up.
-He used it to control his television.
*There was no sign at the entrance to the room or within the room that indicated an audio monitoring device was used in that room.
6. Observation and interview on 11/6/24 at 9:55 a.m. with resident 41 and her husband in her room revealed:
*Her room was located on the provider's secure Memory Care Unit (MCU).
*There was no sign at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room.
*A family interview was conducted with the resident and her husband in this room with the expectation of privacy.
Observation on 11/8/24 at 8:43 a.m. of resident 41's room revealed:
*No signage at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room.
*An audio/video monitoring device, HelloBaby, sat on her dresser in the room with the camera pointed toward the room.
Review of resident 41's EMR revealed:
*There was no documentation resident or family consent was obtained for the use of an audio/video monitoring device.
*There was a handwritten and undated care plan intervention, I have a camera in my room to help monitor my safety as well as to monitor other residents who may wander in my room.
7. Observation and interview on 11/7/24 at 4:21 p.m. with resident 27 and certified medication aide (CMA) I in resident 27's room revealed:
*An iFamily audio/video camera was on the shelf in her room.
-The camera had both audio and video functions.
*She had turned the camera away from her while assisting resident 27.
*An Echo Show device was located on her nightstand between the recliner and the bed.
-That device was provided by resident 27's family.
-CMA I stated that resident 27's family used that device to talk to other family members when they visited.
-CMA I was unaware if that device allowed the family to listen or watch the care provided.
*She would have known which resident rooms had a video camera because it was on their daily worksheet.
*There was no sign at the entrance to the room or within the room that indicated audio/video monitoring devices were used in that room.
Observation and interview on 11/7/24 at 4:30 p.m. with CMA I at the Cotton [NAME] Court neighborhood nurse's station revealed:
*The audio/video monitoring screen was positioned facing into the nurse's station.
-That screen was visible when facing the nurse's station when you looked to the right side.
-That screen could have been seen by a public visitor when standing at the nurse's station.
*CMA I confirmed that this device was used by resident 27 because she is the only one in this neighborhood with a camera.
*CMA I confirmed that the cameras are listed on the resident care plan.
*She stated that all staff who walked by should watch to make sure that resident 27 did not have a fall.
-The audio/video monitoring camera and screen remained on even when the resident was not in their room.
*She demonstrated the audio and pan and tilt features of the audio/video camera.
-The camera viewing angle in resident 27's room was changed with the use of the control features of the monitoring screen at the nurse's station.
-That allowed the viewing angle of the camera inside the resident's room to be remotely changed from outside the room.
8. Review of the provider's neighborhood daily worksheets revealed:
*The Cotton [NAME] Report Sheet was undated.
-It did not indicate that resident 27 had an audio/video monitoring device.
*The Willow [NAME] Way Pocket Guide was undated.
-It did not indicate that residents 2, 13, and 22 had audio/video monitoring devices.
*The [NAME] Creek Pocket Guide was updated on 11/7/24.
-It did not indicate that residents 19, 28, and 106 had video or audio monitoring devices.
*The Maple Valley Report Sheet was undated.
-It indicated residents 21, 41, 47, 49, and 52 had a *Camera in their rooms.
-Related to resident 48 it indicated FYI- CAMERA IN ROOM FROM FAMILY - THIS DOES RECORD.
9. Observation on 11/08/24 at 8:13 a.m. of the [NAME] Creek nurse's station revealed:
*One audio/video monitoring screen on the counter facing the nurse's station.
-There was no indication as to which resident room was being displayed.
-That screen was visible when facing the nurse's station when you looked to the right side.
-That screen could have been seen by a public visitor when standing at the nurse's station.
*The audio/video monitoring device had a pan and tilt feature that allowed the viewing angle of the camera inside of the resident's room to be remotely changed from outside the room.
Interview on 11/08/24 at 8:26 a.m. with CMA J regarding the audio/video monitoring devices used on [NAME] Creek revealed:
*Resident 28 and resident 106 had video cameras in their rooms.
-They were both the same kind.
*The viewing monitor was kept at the nurse's station, but it could have been unplugged and carried by staff when needed.
-All staff were responsible for looking at the audio/video monitoring screen at the nurse's station for resident safety.
*She would have known which residents had video cameras in their rooms because they are in the room, and I can see them.
*She was unaware if any family-provided audio or monitoring devices had been used in that neighborhood.
Observation and interview on 11/08/24 at 8:41 a.m. with CMA K at the [NAME] Way neighborhood nurse's station revealed:
*Two audio/video monitoring screens faced the nurse's station.
-One was labeled keep vol [volume] on.
-There was no indication of which residents' rooms were monitored.
-Those screens were visible when facing the nurse's station when you looked to the left side.
-Those screens could have been seen by a public visitor when standing at the nurse's station.
-The audio/video monitoring device remained on even when the resident was not in their room.
*CMA K stated the audio/video monitors were used for resident 22 and resident 13.
-The video cameras were used as fall interventions on their care plans.
-All staff were responsible for implementing fall interventions.
*The audio/video monitoring device had a pan and tilt feature.
-This allowed the viewing angle of the camera inside the resident's room to be remotely changed from outside the room.
10. Observation on 11/8/24 at 8:33 a.m. of resident 49's room revealed:
*His room was located on the Maple Valley wing on provider's secure MCU.
*There was a HelloBaby audio/video device plugged in and sitting on his four-drawer dresser in front of his flat screen television.
*There was no signage on his door or in his room that indicated an audio/video device was in his room.
Review of resident 49's EMR revealed:
*There was no documentation resident or family consent was obtained for the use of an audio/video monitoring device.
*There was a handwritten and undated care plan intervention I have a camera in my room to promote my safety.
11. Observation on 11/8/24 at 8:36 a.m. of resident 47's room revealed:
*Her room was located on the Maple Valley wing on the provider's MCU.
*There was a vtech audio/video monitoring device plugged in with a MIC [microphone] and the indicator light that was on and green, which indicated the device was on.
*Her room door had no signage that indicated audio/video monitoring.
Review of resident 47's EMR revealed there was no documentation resident or family consent was obtained for the use of an audio/video monitoring device.
12. Observation and interview on 11/8/24 at 8:40 a.m. with resident 52's husband and of her room revealed:
*Her room was located on the Maple Valley wing in the MCU.
*She and her husband were in the room and he was aware of the audio/video monitoring with no concerns expressed.
*He stated the purpose of the device was related to his wife's falls and to keep her safe so the staff could respond if she falls.
*Her room door had no signage that indicated audio/video monitoring.
Review of resident 52's EMR revealed there was no documentation resident or family consent was obtained for the use of an audio/video device.
13. Observation and interview on 11/08/24 at 8:56 a.m. with resident 2 in her room revealed:
*An audio/video communication device with a screen she called a portal was on her nightstand next to her recliner.
*She stated she used the device to talk to her family.
-I just say 'hey portal' call whoever I want to call.
*She stated it also rang like a telephone, but she could answer it with her voice.
*She stated she could see her family on the screen, and they could see her.
*There was no sign at the entrance to the room or within the room that indicated an audio/video device was used in that room.
14. Interview on 11/8/24 at 8:55 a.m. with nursing assistant (NA) W revealed she:
*Was recently hired on 10/8/24 and was training to be a CNA.
*Was aware of audio/video monitoring in some of the residents' rooms.
*Stated the audio/video monitoring had not been discussed at the facility's new employee orientation she had attended.
*Became aware of the audio/video monitoring when she saw the video monitors at the nursing station's desk.
*Stated At least three [residents] have it in their room.
Continued interview on 11/8/24 with NA W revealed that the audio and video monitor was on for resident 41's device and stated staff can't really hear it, unless we turn it up.
15. Observation on 11/8/24 at 9:00 a.m. of the nursing station in the provider's MCU revealed five audio/video monitoring units were located on the nurses' station desk area with their screens on and turned toward the kitchenette area.
16. Interview and observation on 11/8/24 at 9:08 a.m. with housekeeper X in Maple Valley MCU revealed she:
*Had been working at the facility for seven months.
*Stated she was aware of the video monitoring in some of the resident rooms.
*Showed this surveyor resident 48's room that had a video camera placed on top of the resident's wardrobe aimed at her bed.
*Noted a pink sign on the resident's wardrobe that stated Video Monitoring/Recording in Progress. Please do not Move Camera per Family Request.
-She stated today was the first day she noticed that sign on her wardrobe.
-She stated she was not aware of all the rooms that had audio/video monitoring but said video monitoring cameras were in some of the resident rooms in other wings.
*Could not recall if the audio/video recording had been discussed during her new employee orientation.
*Showed this surveyor resident 21's room in the MCU and the iFamily video camera on her dresser and agreed there was no sign displayed of the audio/video monitoring.
17. Interview on 11/8/24 at 9:15 a.m. with CNA/CMA Y revealed:
*There were five facility placed audio/video monitors in the MCU.
*The audio/video monitors were used by staff to watch for the residents who would rise from their beds at night as a fall prevention.
*The staff would also make rounds every couple of hours in the resident wings.
*Resident 48's family had placed a video camera in her room.
*The facility placed audio/video monitors were not recording devices.
*The audio/video monitors all had audio so the staff could also hear what was occurring.
18. Interview on 11/8/24 at 9:41 a.m. with RN G revealed she:
*Was the MCU's neighborhood leader.
*Stated the audio/video monitoring was used as an intervention for falls.
*Pointed to where the audio/video monitors were located on the nursing station desk and stated residents did not typically come into the nurse's station area.
*Agreed the audio/video monitoring had occurred during the time of the family interview with resident 41 and her husband on 11/6/24.
*Stated staff informed and cleared the audio/video monitoring with the family but did not ask the family to sign an acknowledgment of the monitoring.
-That family conversation would be noted in a progress note.
-Audio/video monitoring was included in the resident's individual care plan.
*Stated It's a thought when asked if the provider should have signage posted for the audio/video monitoring.
19. Interview on 11/08/24 at 11:30 a.m. with administrator A regarding the provider's privacy policy revealed:
*They reviewed resident rights at admission and residents would sign an acknowledgment at that time.
*The resident admission packet was provided to the survey team during the entrance conference.
-All information covered during a resident's admission would be found there.
*There was no specific privacy policy.
-The residents' right to privacy was covered in that admission packet.
20. Observation and interview on 11/08/24 at 11:50 a.m. with DON B regarding the use of audio/video monitoring devices revealed:
*The provider used audio/video monitoring devices in several residents' rooms.
-There were several different brands of devices.
-All the devices used had audio and video capabilities.
*Audio/video monitoring devices were used as a fall intervention.
*The interdisciplinary team (IDT) reviewed residents to determine the need for an audio/video monitoring device.
*Audio/video monitoring devices not being used were stored in the DON's office or the nurse's storage room.
-All nursing staff and maintenance had access to the nurse's storage room where the extra audio/video monitoring devices were kept.
-It was confirmed that there were no devices in the nurse's storage room.
*There was one audio/video monitoring device in the DON's office.
-That device had been removed from resident 106's room because it should not have been in that room.
-It [the audio/video monitoring device] must have been left at the nurse's station when a different resident discharged .
-She was looking into how it got there [resident 106's room].
*She kept a list of residents who had audio/video monitoring devices.
-Resident 106 was not on that list.
*She expected that the family would have been notified and consent would have been obtained when the audio/video monitoring device was recommended by the IDT.
-Those devices should have been added as an intervention to each resident's care plan who had one in their room.
*Family members had provided other devices including [NAME] and Echo devices to residents.
-They were to be added to the care plan.
*She confirmed that they had not posted any notice in the resident's room about audio/video monitoring devices used in those rooms.
*She had not considered the need for privacy during interviews with residents and their families conducted by the survey team or when residents visited with family or other visitors.
-She stated staff should turn the camera in the room while providing care.
Interview on 11/08/24 at 11:59 a.m. with DON B regarding resident consent and care plans revealed:
*They did not use a consent form for audio/video monitoring devices in residents' rooms.
*Staff would have documented in the resident's EMR when families would have been notified of the use of an audio/video monitoring device as a fall intervention.
*She had provided a copy of all the notifications to families for residents with an audio or video monitoring device that had been completed.
-She confirmed that she had been unable to locate notifications to the family for residents 13, 41, 47, 49, 52, and 106.
*She confirmed that the care plan had not been updated for resident 13.
*She stated resident 106's care plan would not have been updated, because resident 106 had not been reviewed by the IDT for audio/video monitoring device use.
21. Review of the provider's un-dated Resident admission Packet revealed:
*admission ACKNOWLEDGEMENTS.
-The undersigned resident/responsible party acknowledges receipt of the following information. Check the list below.
--Resident [NAME] of Right.
*A consent form, 8. [NAME] HOME PATIENT & RESIDENT RIGHTS: I have received a copy of the [NAME] Home Patient & Resident Rights form and understand it.
*PRIVACY ACT STATEMENT- HEALTH CARE RECORDS.
-THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PROVACY ACT OF 1974. THIS FORM IS NOT A CONSENT FORM .
*A South Dakota State Long-Term Care Ombudsman Program packet.
-You have the right to privacy and confidentiality regarding personal, financial, and medical affairs .
--A facility must permit you to: . 2. Use a telephone without being overheard 7. Meet with people in a private setting within the facility.
22. Review of the iFamily Baby Monitor SM650 User Manual revealed:
*PAN AND TILT The camera unit can be remotely controlled from the Monitor Unit.
*Volume +/ Up key: Press Volume+ to increase the volume
Review of the provider's 2/1/24 Video/Audio Monitoring and Recording policy revealed:
*This policy outlines the rules for deploying such devices to ensure security, safety and the protection of resident's privacy.
*[NAME] allows the use of video monitoring on the campus.'
*Management, residents or their authorized representatives may place video monitoring devices in residents' rooms.
*Placement of Monitoring Devices owned by [NAME]
-[NAME] may place video monitoring devices in resident's rooms/apartments if deemed appropriate and approved by the Administrator, or designee, and agreed upon by the resident or their authorized representative.
-Monitoring devices placed in residents' rooms/apartments should be positioned to minimize the monitoring of private areas such as restrooms, bathing areas, and the changing areas as much as possible.
*Resident Owned Monitoring.
-Before initiating video monitoring, a resident shall provide notice and consent to [NAME].
*The policy did not identify a need to post notices at the entrance to the resident's room that a monitoring device was operational in that room.
*The policy did not identify a need to obtain consent for the placement of monitoring devices owned by [NAME]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview, record review, and policy review, the provider failed to implement an effective grievance process to ensure a resident's right to file grievances included documentation, investigat...
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Based on interview, record review, and policy review, the provider failed to implement an effective grievance process to ensure a resident's right to file grievances included documentation, investigation, and follow-up with the resident and the resident's representative's grievances regarding issues of resident care and quality of life that were important to the resident. That failure had the potential to affect all 52 residents.
Specifically, the provider failed to ensure the following:
*All written grievance decisions included the date that the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to have been taken by the provider as a result of the grievance, and the date the written decision was issued.
*Maintenance of grievance documentation for a period of no less than three (3) years from the issuance of the grievance decision.
*Prompt efforts to resolve grievances and to have kept the residents informed of progress toward the resolution.
*Staff completed a grievance form if given an oral grievance, investigated and followed up with the resident and their representative.
*The resident council was informed in writing of the responses to concerns brought up in the resident council meetings and provided a prompt update on efforts by the provider to resolve any grievances.
Findings include:
1. Interview on 11/5/24 at 2:29 p.m. with resident 20 revealed she:
*Had lived at the facility for the past three years.
*Had concerns regarding the food served to the residents.
-Those concerns happened routinely enough to be significant.
-She stated there were other residents who had food concerns.
-Her food concerns had been Since I've been here . and had not been addressed.
*She had voiced those food concerns:
-To staff.
-At the monthly resident council meeting.
-At her care plan conferences.
2. Interview on 11/6/24 at 9:55 a.m. with resident 41 and her husband revealed he had some concerns regarding:
*The other day he had purchased some items at the provider's BINGO store and had placed those items, including deodorant and a new toothbrush, into a bag with his wife's name on it and place the bag on the chair in his wife's room.
*The next day the bag was gone.
-He mentioned it to the housekeeper and other staff.
-Staff found the missing bag in another resident's room.
*About two months ago fish was served on Fridays for lunch.
-The fish was awful.
-It happened repeatedly enough that he let the staff know about his concern with the fish served.
-He had not received a resolution to his concern, but stated the last few times the fish was wonderful.
Interview on 11/8/24 at 9:47 a.m. with registered nurse (RN) G revealed:
*She was the neighborhood leader for the Memory Care Unit (MCU).
*She recalled the husband of resident 41 discussing his concern regarding the missing bag of items from the BINGO store.
*She had not written the concern down or made a progress note regarding the concern and she felt they had investigated and resolved that concern.
*When asked about how she handled concerns she stated:
-I would ask family if they want to officially fill out a grievance form.
-She would not fill out a grievance form for lost clothing.
-She had not filled out any grievance forms for concerns she had received.
-Social services director C had filled out grievance forms.
3. Review of the 8/28/24 Resident Council meeting minutes revealed the following food concerns:
*The pork chops were too dry and tough.
*More options for sandwiches and types of bread were requested.
*Having cottage cheese on the menu more often.
*Bread has been . stale.
*More variety in the desserts was requested.
*Less green beans and peas.
Review of the 9/25/24 Resident Council meeting minutes revealed the following:
*Food concerns:
-Pork Chops have been very tough.
-The ham was served . too thick to cut properly.
-The Morning sausage has been too hard.
*Housekeeping concern that clothing is being lost in the laundry more often.
*Activity concern that four residents attending the meeting would like their nails done .
*No follow-up to the concerns raised at the August resident council meeting including the steps taken to investigate the concerns, actions taken, or the resolution was provided.
Review of the 10/29/24 Resident Council meeting minutes revealed the following:
*Food concerns:
-Porkchops are still pretty tough to eat .
-More variety in salad dressings was requested.
-A preference for shredded lettuce.
-Chili that isn't so spicy .
*Maintenance concern that resident 1, who attended the meeting, wants her wheelchair fixed.
*Activity concern with three residents' nail care.
*Nursing care concerns with morning staff and Traveling aides are not always helpful.
*No follow-up to the concerns raised at the September resident council meeting including the steps taken to investigate the concerns, actions taken, or the resolution was provided.
On 11/6/24 at 1:13 p.m. a request was made from administrator A for the provider's grievance log.
4. Interview on 11/6/24 at 4:28 p.m. with administrator A revealed:
*The provider had no grievances that were logged.
*Administrator A stated they had no formal grievances.
*For resident concerns, the staff would review the concern, investigate and work on solutions to address the issue.
*The provider did not have any written documentation to ensure the prompt effort, progress towards, and resolution of all grievances.
5. Interview on 11/8/24 at 10:27 a.m. with life enrichment director F revealed she:
*Had worked the past three years at the facility.
*Coordinated the monthly resident council meetings.
-Documented the resident concerns expressed in the meeting minutes.
-Provided the meeting minutes to the department directors.
-Stated sometimes we get a response.
*Had not filled out a grievance form for the resident concerns expressed.
*Was not aware of any plan in place to address the residents' concern with the pork chops expressed at the August, September, and October resident council meetings.
*She had discussed official grievances with social services director C and she helped her fill out a grievance form.
*The last grievance was over a year ago regarding a dietary concern.
6. Review of the provider's admission packet received at the start of the survey on 11/5/24 revealed an undated Resident Grievance form that included four paragraphs.
Interview on 11/8/24 at 11:30 a.m. with administrator A revealed:
*The above undated Resident Grievance form was the provider's old policy.
*He had provided the updated November 2017 Resident Grievance policy that morning, 11/8/24.
Interview on 11/8/24 at 11:32 a.m. with social services director C revealed she:
*Had worked for the past six years at the facility.
*Stated there was a difference between a concern and a grievance.
-A concern was minor and was any problem for the resident or family
-A grievance would be something more major.
*Stated not all concerns would amount to a grievance.
*Stated the provider had not had an official grievance for the past year.
*Stated resident or family concerns were discussed and forwarded to the appropriate departments but the provider did not track these concerns.
Further interview with social services director C regarding the provider's Resident Grievance policy revealed:
*The old, undated Resident Grievance form obtained from the admission packet at the start of the survey on 11/5/24 was the form she discussed at the time of a resident's admission.
*She was not aware of the updated November 2017 Resident Grievance policy.
*She agreed she was using an outdated form and she stated she would update the admission packet to include the current policy.
*She confirmed they had no formal grievance tracking system.
7. Review of the provider's November 2017 Resident Grievance policy revealed:
*Grievance forms are available on each neighborhood.
*If a resident and/or resident representative has a grievance it can be written on this form.
*The form is then directed to the Social Services Office .
*The facility Administrator, Social Worker, Department Supervisor or Facility Designee will respond to the resident and/or responsible party in writing in a prompt manner as to their efforts to resolve the grievance.
*All grievances and facility responses will be kept on file in the Social Services Office.
*Residents may express grievances at Resident Council Meetings.
*If a grievance is voiced at the Resident Council Meeting involving specific departments, the grievance will be responded to directly by the respective Department Supervisor in a prompt manner as a follow-up at the next Resident Council Meeting.
*A resident and/or responsible party may wish to personally contact the Social Services Staff or Administrator to discuss a grievance he or she might have.
*No definitions or guidance was provided regarding the difference between a concern and a grievance.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, record review, and job description review the provider failed to ensure the dietitian and dietary director carried out the functions of the food and nutrition services...
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Based on observation, interview, record review, and job description review the provider failed to ensure the dietitian and dietary director carried out the functions of the food and nutrition services department to ensure the development and implementation of policies and procedures regarding appropriate cleaning, sanitization, and record-keeping were completed in the food and nutrition departments that included the main kitchen and four kitchenettes. Failure to ensure this oversight of the food and nutrition services department increased the potential risk of foodborne illnesses for the entire resident population who received meals that were prepared in the main kitchen and served from the kitchenettes. Findings Include:
1. Refer to F812
2. Interview on 11/08/24 at 12:36 p.m. with dietary director (DD) E revealed:
*She was a certified dietary manager.
*She had been in her current position for two months.
*She had not been aware of the regulations in nursing home kitchens.
-Her previous position was not in a nursing home.
*She had not seen the policies requested by the survey team until that week.
*Consultant registered dietitian (CRD) H visited once a week on Thursdays.
-Those visits were not recorded.
--CRD H documented in residents' medical records.
---She confirmed that CRD checked-in with her during those visits.
*There were no food service related audits being conducted that she was aware of.
*No food service related audits had been completed since she started that she was aware of.
Review of the provider's undated Dietary Director Position Description revealed:
*The Dietary Director is responsible for coordinating the food service program to provide nutrition and variety within a budget. Consult with residents, staff, and dietician to ensure that therapeutic diet needs of residents are met.
*The supervisor was listed as the administrator.
*Essential job responsibilities included:
-Consult with dietician as needed and directed according to state regulation and resident need.
-Maintain a clean, orderly and safe kitchen environment.
-Develop and implement policies and procedures in the food service program that are in compliance with food service regulations.
-Adhere to and carry out all policies and procedures.
Review of the providers 7/17/23 Contract for Registered Dietitian Services revealed:
*The purpose of this Agreement is to arrange for Registered Dietitian (RD) consultation and management materials for the above named facility.
-The facility listed above was a sister facility located in Sioux Falls.
*Responsibilities of the Consultant Dietitian included:
-Consults with Administration regarding planning of Food & Nutrition Service department policy Development, establishing goals and priorities in integrating Food & Nutrition Services into the Facility's total program.
-Supports the Food & Nutrition Services Supervisor in maintaining department standards and all applicable regulations related to food procurement, receiving, storage, preparation, and service.
-Assists in evaluating, developing and/or writing Food Service Policies and Procedures.
-The Facility and [contract company name] shall mutually, on a periodic basis, review and approve the Food & Nutrition Services policies and establish future goals.
-[Contract company name] may make recommendations to ensure quality food service and/or to comply with rules and regulations of the Federal or State governments. The Facility, however, is responsible for approving, implementing and maintaining recommendations made by [contract company name].
*The contract was not signed by the current facility administrator.
Review of the provider's undated Maintenance Director Position Description revealed:
*The Maintenance Director is responsible to maintain building and grounds.
*The supervisor was listed as the administrator.
*Essential job responsibilities included:
-Carry out the preventative maintenance program.
-Repair or replace damaged or broken fixtures or equipment.
-Carry out other tasks as assigned by supervisor.
*Knowledge Expectations included: Function and operation of kitchen appliances, office equipment maintenance equipment and grounds equipment, with ability to do minor repairs.
*The position description review did not reveal oversight of the kitchenettes or monitoring of the kitchenette dishwasher temperatures.
Jul 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and policy review, the provider failed to ensure physician's orders and self-administration of medication assessments had been completed for one of thre...
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Based on observation, interview, record review, and policy review, the provider failed to ensure physician's orders and self-administration of medication assessments had been completed for one of three sampled residents (34). Findings include:
1. Observation and interview on 7/19/23 at 2:38 p.m. with resident 34 revealed she:
*Was at the nurse's station seated in her wheelchair.
*Had a clear plastic medication cup that contained multiple pills and tablets placed in her lap.
*Would take them to her room and administer them herself.
*Had several empty medication cups on different surfaces in her room.
*Stated she had taken the medications. I take them by myself to keep my independence.
Review resident 24's of medical record revealed an assessment signed by the nurse, physician, and pharmacist to only have cough drops and a nebulizer medication as self-administration medications.
Interview on 7/19/23 at 3:50 p.m. with registered nurse (RN) E revealed:
*She had given resident 34 her 2:00 p.m. medications.
*She had always let resident 34 take her medications to her room and self-administer.
*She was unaware resident 34 had required a physician order and a self-administration of medication assessment to have been able to self-administer her own medications.
*Resident 34 doesn't like anyone to watch her take her pills.
Interview on 7/19/23 at 4:55 p.m. with director of nursing B revealed resident 34 had only been approved for self-administration of medications for cough drops and administering her nebulized medication after the nurse had set it up. RN E should not have let resident 34 take the medications to her room and should have observed her taking those pills.
Review of the provider's July 2023 Self-Administration of Medications policy revealed:
*Resident's have the right to self-administer medications if the interdisciplinary team and the resident's attending physician and consulting pharmacists have determined that it is clinically appropriate and safe for the resident to do so.
*At least every three months, the licensed nurse, pharmacist and attending physician shall evaluate and record the continued appropriateness of the resident's ability to self-administer medications.
*No resident may keep medications of the resident's person in the resident's room without a medication order allowing self-administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
Based on interview, record review, and policy review, the provider failed to ensure one of one sampled resident (38) was given advanced notification that she would have been getting a roommate. Findin...
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Based on interview, record review, and policy review, the provider failed to ensure one of one sampled resident (38) was given advanced notification that she would have been getting a roommate. Findings include:
1. Interview on 7/18/23 at 2:05 p.m. with resident 38 regarding the new roommate revealed:
*She was not able to state that she had received a notice from the facility that she would have been getting a roommate.
*She was not happy that she had a roommate.
Review of resident 32's progress notes revealed:
*Licensed Clinical Social Worker (LCSW) C had informed resident's family member on 6/28/23 at 2:14 p.m. that they would be moving her in with another resident when she was off of COVID isolation.
Review of resident 38's progress notes revealed:
*LCSW C had informed resident's family on 7/12/23 at 2.:36 p.m. by email that .Mom did get a roommate today.
*There had been no previous communication with resident's family about her getting a roommate.
Interview with LCSW C on 7/20/23 at 10:06 a.m. revealed:
*She was not aware that the facility needed to give any notification when a resident was getting a roommate.
*She assumed that resident 38 had known she would be getting a roommate at some time since she was in a double room.
*Resident 38 was not notified of the roommate until the day the roommate moved in.
*She assumed that resident 38 would have been okay with a roommate since she had a roommate in the previous facility where she had lived.
Interview with Administrator A on 7/20/23 at 2:18 p.m. revealed he:
*Was not aware that a resident needed to have advanced notice when getting a roommate.
*Was not aware that the facility had a policy regarding roommates.
*Had verbalized to the resident at admission that there was a possibility that since resident 38 was in a double room that she might get a roommate at some point.
*Agreed the facility should have provided written notice to resident 38 before the new roommate moved in.
Review of facility's 8/25/22 Resident Roommate Choice Policy revealed:
*Policy Interpretation and Implementation
-2. Existing residents will be provided with a written notice of need for a roommate or roommate change with as much notice as possible.
-4. Written consent for choice of roommate and/or agreement with a roommate assignment will be obtained prior to roommate placement.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
2. Observation on 7/20/23 at 7:51 a.m. of CNA/MA M revealed she:
*Placed 17 grams (gm) of MiraLAX powder into resident 46's glass of cranberry juice.
*Placed the glass of cranberry juice onto resident...
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2. Observation on 7/20/23 at 7:51 a.m. of CNA/MA M revealed she:
*Placed 17 grams (gm) of MiraLAX powder into resident 46's glass of cranberry juice.
*Placed the glass of cranberry juice onto resident 46's breakfast tray.
*Medication for resident 46 had been placed on her breakfast tray.
-Medications that had been prepared included:
--Allopurinol Tablet 100 milligram (mg) by mouth.
--Certa Vite/Antioxidants one tablet by mouth.
--Folic Acid 1 mg by mouth.
--Lasix 80 mg by mouth.
--Meloxicam 15 mg by mouth.
--MiraLAX Powder 17 gm/scoop 1 scoop.
--Nameda 5 mg by mouth.
--Metoprolol 50 mg by mouth.
--Senna 8.6 mg tablet 1 tablet by mouth.
--Tramadol 50 mg by mouth for moderate pain.
---Pain rating 0/10.
-Vitamin C 500 mg by mouth.
-Gabapentin 400 mgby mouth.
*RN E delivered the breakfast tray to resident 46's room and then returned to the nursing area without ensuring the resident had taken her medication.
Interview on 7/20/23 at 8:00 a.m. with CNA/MA M regarding resident 46's medication revealed:
*She had prepared resident 46's medication and placed them on the breakfast tray.
*RN E had taken the tray into the resident's room.
*All the medication RN E had delivered to resident 46's room had been signed off on 7/20/23 at 8:00 a.m. by CNA/MA M.
Interview on 7/20/23 at 8:15 a.m. with resident 46 regarding her morning medication that were administered revealed:
*She usually ate her breakfast in her room and her medication would be on her tray.
*Staff did not stay in her room to make sure she had taken her medication.
Interview on 7/20/23 at 2:30 p.m. with director of nursing (DON) B regarding the above observation revealed:
*Staff that dispensed the medication from the medication card should have been the person to administer the medication.
*Staff should have stayed in the resident's room to make sure the medication had been taken by the resident.
Review of the provider's June 2023 Medication Administration Policy revealed:
*Medication was not to have been left unattended. The nurse or MA must visualize the resident taking their medication.
*Residents may self-administer their own medication only if the physician in conjunction with the interdisciplinary care planning team, had determined that they have the decision-making capacity to do so safely.
*A person may not administer medications that have been prepared by another person.
Based on observation, interview, record review, and policy review, the provider failed to ensure one of one registered nurse (RN) E and one of one certified nurse aide/medication aide (CNA/MA) M had administered medications according to the provider's policy for two of two sampled residents (34 and 46). Findings include:
1. Observation and interview on 7/19/23 at 2:38 p.m. with resident 34 revealed she:
*Was at the nurse's station seated in her wheelchair.
*Had a clear plastic medication cup that contained multiple pills and tablets placed in her lap.
*Would take them to her room and administer them herself.
*Had several empty medication cups on different surfaces in her room.
*Stated she had taken the medications. I take them by myself to keep my independence.
Review resident 24's of medical record revealed an assessment signed by the nurse, physician, and pharmacist to only have cough drops and a nebulizer medication as self-administration medications.
Interview on 7/19/23 at 3:50 p.m. with registered nurse (RN) E revealed:
*She had given resident 34 her 2:00 p.m. medications.
*She had always let resident 34 take her medications to her room and self-administer.
*She was unaware resident 34 had required a physician order and a self-administration of medication assessment to have been able to self-administer her own medications.
*Resident 34 doesn't like anyone to watch her take her pills.
Interview on 7/19/23 at 4:55 p.m. with director of nursing B revealed resident 34 had only been approved for self-administration of medications for cough drops and administering her nebulized medication after the nurse had set it up. RN E should not have let resident 34 take the medications to her room and should have observed her taking those pills.
Review of the provider's July 2023 Self-Administration of Medications policy revealed:
*Resident's have the right to self-administer medications if the interdisciplinary team and the resident's attending physician and consulting pharmacists have determined that it is clinically appropriate and safe for the resident to do so.
*At least every three months, the licensed nurse, pharmacist and attending physician shall evaluate and record the continued appropriateness of the resident's ability to self-administer medications.
*No resident may keep medications of the resident's person in the resident's room without a medication order allowing self-administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
5. Observation and interview on 7/19/23 at 2:00 p.m. of LPN F during resident 16's dressing change revealed:
*She had performed hand hygiene and donned gloves before removing the resident's soiled dre...
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5. Observation and interview on 7/19/23 at 2:00 p.m. of LPN F during resident 16's dressing change revealed:
*She had performed hand hygiene and donned gloves before removing the resident's soiled dressing.
*After she had removed the resident's soiled dressing she removed her gloves.
*No hand hygiene was observed before she had placed on clean gloves.
*A new dressing was then placed on the resident's wound.
*LPN F agreed she should have performed hand hygiene after removing her soiled gloves and before putting on a pair of clean gloves.
6. Observation on 7/19/23 at 3:07 p.m. of LPN D during resident 15's personal care revealed:
*The resident was in her bathroom and was seated on the toilet.
*She had dime-sized pressure wounds on her bilateral buttocks that were covered with a layer of barrier cream.
*LPN washed her hands for five seconds in the resident's bathroom before putting on a clean pair of gloves.
*LPN then cleansed the resident's perineal area.
*LPN placed a new layer of barrier cream to the resident's bilateral buttocks.
-There was no observation of LPN D removing her soiled gloves, performing hand hygiene, and putting on a clean pair of gloves before applying a new layer of barrier cream on her bilateral buttocks.
Review of the provider's revised September 2012 Infection Control Guidelines for All Nursing Procedures policy revealed:
*Employees must wash their hands for twenty seconds with soap and water that included the following conditions:
-Before and after direct contact with residents.
-After removing gloves.
*If hands were not visibly soiled, staff may use an alcohol-based hand rub for all of the following situations:
-Before and after direct contact with residents.
-Before handling clean or soiled dressing.
-Before moving from a contaminated body site to a clean body site during resident care.
-After handling used dressings.
Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices had been maintained for the following:
*Hand hygiene and glove use for two of three observed resident (16 and 40) dressing changes by two of two registered nurses (RN) (E and L) and one of one licensed practical nurse (LPN) F.
*Hand hygiene and glove use during personal care for two of four observed residents (15 and 29) by certified nursing assistant (CNA (N) and LPN D.
*Hand hygiene and glove use by one of one RN (L) for two of two observed residents (42 and 44) in the dining room.
Findings included:
1. Observation on 7/18/23 at 10:36 a.m. with CNA N while she assisted resident 29 to the toilet revealed she:
*Put on gloves without any hand hygiene.
*Assisted resident 29 from her wheelchair to the toilet.
*Removed the soiled pull-up brief and placed the brief in the garbage bag.
*Looked for some wet wipes in the bathroom, including opening up resident 29's roommate's storage bin. *Removed the gloves and without performing hand hygiene left the room.
*Returned a few minutes later to the resident's room with a new package of wet wipes.
*Put on a pair of gloves without performing hand hygiene.
*Assisted the resident to a standing position.
*Performed perineal care after the resident urinated a small amount when she had stood up.
*Helped resident 8 to pull up the brief and pants.
*Put the soiled brief in a bag, removed her gloves, took the garbage bag down the hall, and disposed of it in the garbage.
2. Observation on 7/18/23 at 11:45 a.m. of RN L revealed she was assisting residents to eat lunch in the dining room. Resident 42 had a bloody nose. RN L took a tissue and rolled the end up slightly and then put it in the residents right nostril. She then took the tissue out of the resident's nostril. She had not completed hand hygiene after helping resident 42 with the bloody nose and then went back to assist resident 2.
3. Observation on 7/19/23 at 8:00 a.m. revealed resident 44 complained that her toes hurt. RN L took off her sock looked at and touched resident 44's toes. She put the sock back on her foot. She had not put on gloves prior to looking at or touching resident 44's toes. RN L had not completed any hand hygiene and returned to assisting other residents with breakfast.
4. Observation on 7/19/23 at 8:25 a.m. revealed RN's E and L entered resident 42's room for a dressing change to her left lower leg.
*Both RN E and RN L put on gloves after washing their hands for less than five seconds and shut off the faucet with their wet bare hands.
*RN L moved the garbage can closer to the overbed table and moved the items off of the table. She then put a towel on top of the overbed table. She had forgot an item and left the room to retrieve it. During that time RN E put on a pair of gloves and removed the soiled dressing from resident 40's left lower leg. She removed her gloves and washed her hands for less than five seconds and shut off the faucet with her wet bare hands. RN L returned and washed her hands for less than five seconds and shut off the faucet with her wet bare hands, and she put on a pair of gloves. She used wound wash to cleanse the skin tear, covered the wound with a Telfa-Tegaderm dressing. She removed her gloves, retrieved a marker from her uniform pocket and initialed & dated the dressing. She disposed of the dressing packages. Both RN's washed hands for less than 5 seconds and shut the faucet off with their bare wet hands.
Interview on 7/20/23 at 9:30 a.m. RN L regarding the missed opportunities for hand hygiene and glove changes. She agreed she should have changed gloves between the cleansing of the wound and applying the new dressing. She agreed she had not completed hand hygiene per the provider's policy for the above observations.
Interview on 07/20/23 at 11:30 a.m. with director of nursing B regarding the above findings agreed there had been several missed opportunities for hand hygiene. She agreed the hand hygiene completed was not up to the standards of practice.
Apr 2022
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to develop person-centered care plans, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to develop person-centered care plans, and revise as needed, to address interventions and resident preference for four of fourteen sampled residents (17, 27, 44, and 55). Findings include:
1.Observation and interview on 4/26/22 at 10:35 a.m. with resident 17 revealed he:
*Had been lying in bed in a dark room.
*Had not participated in activities outside of his room.
*Preferred to stay in his room to watch TV, read or write.
*Had been receiving physical therapy since admission on [DATE].
*Ate his meals in his room.
Review of resident 17's care plan date initiated 2/7/22 created by registered nurse D (RN) revealed he:
*Preferred to consume meals in my room, but staff were to encourage me to eat one meal per day out in the dining room.
*Had no preferences for activities.
Interview on 4/27/22 at 11:14 a.m. with life enrichment coordinator H regarding resident's activities revealed:
*She had known that he preferred to be in his room.
*Would provide in- room activities such as: puzzles, books.
-But had not done that.
*Had visited with the resident in his room, which he liked.
*She would complete an evaluation on new admissions within 48 hours.
*She would re-evaluate a resident if they had not participated in activities and update the care plan.
*She agreed that resident's care plan did not address activities that he had preferred or enjoyed.
*She agreed that no evaluation had been completed since his admission.
2.Observation on 4/26/22 10:06 a.m. of resident 44 revealed he:
*Had been feeding himself breakfast.
*Had been able to answer some questions.
Observation on 4/26/22 at 2:57 p.m. of resident ambulating on the unit.
Record review of resident 44's chart revealed:
*admitted to memory care unit with diagnosis of Alzheimer's disease.
*Had eloped from the memory care unit on 4/10/22,and was found within the facility.
Review of resident 44's care plan dated 5/5/21 revealed:
*He had attempted to leave previous facilities unattended.
*Had been a fall risk.
*High risk for wandering.
*Preferred BINGO, reading the newspaper, visiting and movies to distract from wandering.
*Provide structured activities.
*Identify pattern of wandering.
*No intervention for frequent rounding.
Interview on 4/27/22 at 8:56 a.m. with registered nurse (RN) F revealed they/she:
*Had placed a note on doors to memory care unit to make sure the door closed.
*Did frequent checks on the resident, but that was not documented.
*Agreed that frequent rounding was not on the care plan.
*Had the resident been out of view, staff would look for him.
*He did not have a wander guard.
*Typically wander guard had not been used on a locked unit.
3.Closed record review of resident 55's chart revealed:
*Had utilized hospice services on 2/28/22.
*Passed away on 3/9/22.
Review of resident 55's care plan initiated 5/31/17 revealed:
*Had not been updated to reflect hospice services.
*Had not been updated to focus on areas such as:
-Comfort measures.
Interview on 4/27/22 at 4:47 p.m. with RN F regarding resident 55's care plan revealed:
*Agreed that the care plan had not been updated to reflect that the resident had been on hospice.
*Should have been updated to reflect resident's current plan of care.
Interview on 4/27/22 at 5:46 p.m. with director of nursing B regarding resident 55's care plan revealed she:
*Agreed that resident's care plan had not mentioned being on hospice.
Review of providers Policy of Care dated 3/20 revealed:
*Care plans would be individualized and developed with seven days of the comprehensive assessment.
*Care plans would be updated by staff on an ongoing basis.
4. Observation on 4/27/22 at 10:03 a.m. revealed resident 27:
*Standing in his room beside the right side of his wheelchair alone.
*Held onto the wheelchair handle with his left hand.
*Bent down to lock the brake on the right wheel with his right hand.
*Stepped slowly to the front of his wheelchair and sat down.
*Wheeled himself using his feet towards the bathroom in his room.
Observation and interview on 4/27/22 at 10:10 a.m. revealed RN L:
*Walked into resident 27's and was heard saying, [Resident name}, What are you doing?
*Left the room a few minutes later and explained that he had self-transferred onto the toilet and she helped him get back into his wheelchair.
Interview on 4/27/22 at 10:20 a.m. with RN L revealed:
*She had brought him to his room after he was done eating breakfast.
*He had said he did not need to use the toilet but said he wanted to lie down.
*He would not remember when he had previously used the toilet and was typically up and down.
*She agreed his care plan should be more individualized to describe his risk for falls and person-centered interventions.
Review of the care plan revealed separate but overlapping interventions and tasks:
*A focus created on 3/8/22 of moderate risk for falls that did not:
-Identify the specific risk factors for resident 27.
-State specifically how to anticipate and meet my needs.
-State in what type of physical activity staff should encourage the resident to participate.
-Address the causes to remove based on a review of past falls.
*A separate focus created on 3/9/22 and revised on 3/11/22 of elopement risk/wanderer included a physical activity of walking inside and outside.
*Another separate focus created on 3/9/22 and revised on 3/11/22 of impaired cognitive function/thought processes included activity preferences for exercise (kick ball, balloon volleyball, noodleball).
Review of nursing progress notes revealed the resident had been found lying on the floor on:
*3/19/22 at 1:44 p.m., in the area before the door and he said he did not know what happened.
*4/11/22 at 6:08 a.m., between bed and the wall with a noted smell of BM [bowel movement]. When asked if he needed to use the bathroom, the resident replied, I think I already have.
*4/17/22 at 9:50 a.m., in walkway in front of door with his wheelchair behind him. He said, I was trying to walk.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview, record review, and policy review, the provider failed to ensure consistent and continuous documentation for pressure ulcer monitoring for one of three sampled resident (38) with a ...
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Based on interview, record review, and policy review, the provider failed to ensure consistent and continuous documentation for pressure ulcer monitoring for one of three sampled resident (38) with a pressure ulcer. Findings include:
1. Interview on 4/26/22 at 3:09 p.m. with resident 38 revealed he did not have any open areas that were currently being treated.
Review of the treatment administration record (TAR) for resident 38 revealed orders dated:
*6/28/21 to complete a full skin assessment .every day shift every [Monday].
*3/24/22 to assess Stage 2 pressure injury to right buttock - document appearance and if dressing is not to be changed, document appearance of dressing every day shift.
Review of the weekly full skin assessment eMAR - Medication Administration Note revealed:
*On 3/21/22, a quarter size open area to [right] buttock was found after tub bath.
*There were no documented measurements of the open area on that date or in the weekly skin assessment notes after that date.
*There was inconsistent documentation regarding the color and odor of any drainage and color and character of the tissue and wound edges.
*The weekly assessment on 4/18/22 was missed.
*The 4/25/22 noted no documentation regarding the buttock wound.
Review of the eMAR notes between 3/24/22 and 4/27/22 to assess Stage 2 pressure injury as ordered on 3/24/22 revealed:
*There were no documented measurements of the open area.
*Descriptions for the appearance of the Stage 2 pressure injury were inconsistent, seldom included the condition of the dressing, and did not address whether pain was present.
*The eMAR notes for this order were intermixed among eMAR notes related to other orders making it difficult to determine the progress of healing.
*Four daily eMAR notes were missed, including 4/8/22, 4/12/22, 414/22, and 4/22/22.
Further review of nursing progress notes revealed a weekly Health Status Note that documented measurements of the pressure ulcer:
*On 3/23/22, the pressure ulcer was assessed and measured at 2.5 x [by] 3.5 cm [centimeters], with a beefy red color, moderate drainage, macerated surrounding, skin was moist, and there was no odor.
*On 3/30/22, the measurements were 0.6 x 1.5 cm with a pink wound bed. Surrounding tissue is pink in color as well and blanches. No drainage noted with assessment. Resident reports no discomfort with assessment, but does flinch when assessment is completed.
*On 4/6/22, the measurements were 1.1 x 0.8 cm, Color, wound bed, drainage, odor, and pain were all documented.
*On 4/13/22, no measurements were documented, although the wound is described as fragile and blanching.
*There were no further health status notes after 4/13/22.
Interview 4/27/22 at 3:54 p.m. with registered nurse (RN) D and RN L revealed the process for documentation of skin and pressure ulcer monitoring included:
*A weekly full skin assessment is completed by a nurse on a resident's bath day. The nurse reports if an open area is found.
*The neighborhood leaders would document weekly measurements and assessment of the wound.
*The floor nurses would document daily on the appearance of the dressing and status of the area visible around the dressing or under the dressing if the dressing needed to be changed.
*They agreed the documentation system made it difficult to assess progress towards healing.
Review of the Pressure Ulcer Monitoring and Documentation policy, reviewed on 2/2021, revealed:
*When a PU/PI [pressure ulcer/pressure injury] is present, daily monitoring, (with accompanying documentation .), should include:
1. An evaluation of the PU/PI, in no dressing is present.
2. An evaluation of the status of the dressing, if present .
3. The status of the area surrounding the PU/PI .
4. The present of possible complications .
5. Whether pain, if present, is being adequately controlled.
6. The amount of observation possible will depend upon the type of dressing that is used .
7. With each dressing change or at least weekly .an evaluation of the PU/PI should be documented . and include location, staging, size, drainage, pain, color and character of the wound bed tissue, description of the wound edges and surrounding tissue.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 42% turnover. Below South Dakota's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 15 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $24,385 in fines. Higher than 94% of South Dakota facilities, suggesting repeated compliance issues.
- • Grade F (26/100). Below average facility with significant concerns.
Bottom line: Trust Score of 26/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Bethany Home - Brandon's CMS Rating?
CMS assigns Bethany Home - Brandon an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within South Dakota, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Bethany Home - Brandon Staffed?
CMS rates Bethany Home - Brandon's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 42%, compared to the South Dakota average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Bethany Home - Brandon?
State health inspectors documented 15 deficiencies at Bethany Home - Brandon during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 13 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Bethany Home - Brandon?
Bethany Home - Brandon is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 55 residents (about 92% occupancy), it is a smaller facility located in BRANDON, South Dakota.
How Does Bethany Home - Brandon Compare to Other South Dakota Nursing Homes?
Compared to the 100 nursing homes in South Dakota, Bethany Home - Brandon's overall rating (1 stars) is below the state average of 2.7, staff turnover (42%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Bethany Home - Brandon?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Bethany Home - Brandon Safe?
Based on CMS inspection data, Bethany Home - Brandon has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in South Dakota. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Bethany Home - Brandon Stick Around?
Bethany Home - Brandon has a staff turnover rate of 42%, which is about average for South Dakota nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Bethany Home - Brandon Ever Fined?
Bethany Home - Brandon has been fined $24,385 across 1 penalty action. This is below the South Dakota average of $33,323. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Bethany Home - Brandon on Any Federal Watch List?
Bethany Home - Brandon is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.