Five Counties Nursing Home
Non profit - Corporation
42 Beds
Independent
Data: November 2025
Trust Grade
5/100
#81 of 95 in SD
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Five Counties Nursing Home in Lemmon, South Dakota has received a Trust Grade of F, which indicates significant concerns about the quality of care provided. Ranked #81 out of 95 facilities in the state, this places it in the bottom half, while it is the only option available in Perkins County. The facility's situation is worsening, with the number of reported issues increasing dramatically from 5 in 2023 to 28 in 2025. Staffing is rated average, with a turnover rate of 48%, which is slightly below the state average but may still impact continuity of care. However, there are alarming incidents reported, including a resident developing a pressure ulcer due to inadequate preventative measures and another resident receiving a controlled medication without a prescription, which required emergency medical attention. Additionally, nursing coverage has been inconsistent, with licensed nursing staff not available 24 hours a day for several quarters, raising concerns about the quality of care. While there are some strengths, such as having an average RN coverage, families should be aware of these serious weaknesses when considering this facility.
- Trust Score
- F
- In South Dakota
- #81/95
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $31,850 in fines. Higher than 51% of South Dakota facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for South Dakota. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
5/100
Bottom 15%
Needs review
5 → 28 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 5 issues
2025: 28 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below South Dakota average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 48%
Near South Dakota avg (46%)
Higher turnover may affect care consistency
Federal Fines: $31,850
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 34 deficiencies on record
2 actual harm
May 2025
1 deficiency
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one cognitively impa...
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Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one cognitively impaired sampled resident (3), identified as being at risk for elopement, who eloped (left the facility without staff knowledge) and was outside of the building for an unknown amount of time after she entered the doorlock's key pad code and exited the building. Failure to adequately supervise and monitor the resident's location and to provide environmental controls (doorlock keypad code unknown to the resident) may have contributed to her elopement and placed the resident at risk for an accident and/or injury while she was out of the building and unsupervised.
Findings include:
1. Review of the provider's 4/12/25 SD DOH FRI revealed:
*On 4/12/25 at 11:00 a.m. resident 3 exited the building through the [NAME] wing doors.
-She stated she had entered the door code to unlock it and left as she was looking for her son.
-The door locked behind her.
*She went to the front door of the building and rang the front doorbell.
*At 11:00 a.m., certified medication aide D opened the door for resident 3, and she came back into the building.
*The report indicated resident 3's care plan would be reviewed on Monday [4/14/25] to revise for high-risk elopement.
*The facility ordered AirTags [a tracking device] to assist in monitoring residents' location to ensure safety.
*Resident 3 had refused to utilize the WearTech devices as she insinuates her watch is broken and does not like the emblem on it.
2. Review of resident 3's electronic medical record revealed:
*Her admission date was: 6/7/22
*Her 3/3/25 Brief Interview of Mental Status assessment score was an 8, which indicated she was moderately cognitively impaired.
*Her diagnoses included: dementia with agitation, Alzheimer's Disease, schizophrenia, , altered mental status, and heart failure.
*Her 5/15/25 care plan indicated:
-A 6/14/22 focus area of appropriate placement (a facility with a dementia unit) with a 4/29/25 initiated intervention of Resident high elopement risk, considering other options for a facility better suited for her needs.
-A 6/14/22 focus area of is at moderate risk for wandering and high risk for elopement.
--A 1/31/25 revised goal for this focus area was Resident will remain in facility unless staff present and have no attempts at elopement through the review date.
--The current interventions for that focus area included:
--A 9/9/24 initiated and 9/24/24 revised intervention is a moderate risk for elopement,
--A 4/3/25 intervention Window alarm placed on 4/3/25 in resident room.
--A 4/14/25 intervention is at high risk for elopement, efforts in place to look for a facility more suited to her needs.
--A 4/29/25 intervention Air tag placed in soles of shoes.
*Her 12/3/24 elopement risk assessment indicated she was at moderate risk for elopement.
-Elopement precautions for her included: routine monitoring of her whereabouts, involve in psychosocial programs and activities programs, re-direction, care plan was updated, DON notified, and up-to-date photo in system.
*Her 3/2/25 elopement risk assessment indicated she was at a low risk for elopement.
-Elopement precautions for her included the same as indicated above.
3. Review of the provider's undated Elopement, Risk Reduction Strategies, and Management of Missing Residents policy revealed:
*The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk of elopement, implement risk reduction strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission, and conduct a coordinated resident search in the event of a missing resident.
*Elopement is the ability of a cognitively impaired resident, who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way.
*An elopement risk evaluation is completed on all residents on admission, and with a change in condition or mental status.
*A facility approved risk evaluation tool (or scoring system) is utilized
-a. The evaluation is based on various risk factors that may precipitate an elopement event
-b. The risk score includes a defined parameter which, when reached, indicates an increased risk and prompts strategies, as described below.
*The risk evaluation . addresses the resident's mobility and psychological, behavioral, physical, and cognitive functions. Specific risk factors include:
-Any cognitive impairment which results in an inability of the resident to appreciate safety risks and an inability to protect himself or herself.
-Interference with risk reduction strategies, including an expressed displeasure with a wander bracelet or an attempt to remove it.
-Behavior problems, including those where the resident is not easily redirected or managed when he or she is agitated or aggressive.
*Interventions that may be used for residents identified as high risk for elopement include:
-Frequent monitoring of the resident's whereabouts to assure he or she remains in the facility.
-Implementation of wander bracelet or other electronic alert systems.
-Environmental controls such as:
--The physical plant is secured to minimize the risk of elopement through: (a.) Functional alarm system . c. Safety locks or keypad entry that restrict access to dangerous areas.
*Verification of control systems.
-Door alarm codes are changed routinely.
-Resident electronic monitoring sensors (e.g. bracelets/pendants) will be utilized as needed. They will be checked quarterly for placement and proper functioning and documented in the Care Plan.
*When a resident has been found:
-The resident's service plan [care plan] is updated, including:
--Additional measures such as a wander bracelet if not in current use
--15-minute safety checks or continuous observation if transfer to a more secure facility is determined
--A Missing Resident form is completed, and all staff involved sign the form. The form is forwarded to the Administrator or Resident Services Coordinator.
--The incident is reported to the state authorities as required.
*All elopement attempts and events are documented in the resident record, including objective and factual statements regarding:
-a. Circumstances and precipitating factors
-b. Interventions utilized to return the resident to the unit
-c. The resident's response to the interventions
-d. Results of reevaluation upon the resident's return and the condition of the resident
e. Care rendered
f. Notification of police, physician, and family
g. Physician orders following notification
h. Additional risk reduction strategies implemented
*Resident-specific safety concerns are noted on the resident care plan and interventions that address his or her needs. Interventions to reduce risk are reviewed by the interdisciplinary team on a quarterly basis, at least, or with a change in condition for effectiveness of risk reduction strategies. These measures include realistic measurable goals and avoiding statements such as 'will have no events or no injuries related to elopement'.
*Elopement drills will be conducted annually. Each elopement will be considered a drill and evaluated to improve outcomes.
4. Interview on 5/15/25 at 12:50 p.m. with licensed practical nurse C regarding resident 3 revealed:
*Resident 3 was often exit seeking, and she was aware that resident 3 had recently eloped from the building.
*She thought resident 3 also had an elopement in October 2024, but she was not certain.
*She was not working when resident 3 eloped on 4/12/25, but she was aware of the elopement and the intervention at that time for redirecting resident 3 when she was exit seeking.
*She stated they had not had any elopement drills since she had started her employment.
*She was not aware of a photo book or any other book at the reception desk for residents at risk for elopement.
5. Observation and interview on 5/15/25 at 1:05 p.m. with resident 3 while she was in the activity room revealed:
*She walked independently, without the use of an assistive device such as a walker.
*She stated she did not like living at the facility as she was unable to see her family.
*She did not respond to any additional questions.
6. Interview and policy review on 5/15/25 at 2:43 p.m. with administrator A regarding resident 3's elopement revealed:
*Resident 3 had eloped from the building on 4/12/25.
*Administrator A could speculate that she [resident 3] walked with a visitor out [of the building].
-There were no cameras that would have captured resident 3's elopement.
*She confirmed there was no way to determine how long resident 3 was outside of the building.
*When administrator A interviewed resident 3 after the elopement, resident 3 indicated she had overheard the code to unlock the doors and used it to unlock the door that day.
*There was no signage posted that directed non-staff members to ensure residents did not follow them out of the building when they left.
*Administrator A thought the door alarm codes were changed maybe quarterly.
-The door alarm codes were change after resident 3's elopement on 4/12/25.
-She stated she knew the [door] codes were changed when we have noticed increased wandering and when we heard family screaming out the code.
-There was no documentation of when the door alarm codes were changed.
*She stated staff members were given the code and somehow family and volunteers get a hold of it and then we change it.
*Resident 3 had eloped from the facility more than once, but she was not certain of the dates of those elopements.
*They did not routinely execute elopement drills, but every elopement is reviewed as a drill.
*Regarding the provider's undated Elopement, Risk Reduction Strategies, and Management of Missing Residents policy
-They did not annually photograph residents at risk for elopement.
--She was not certain how often a resident's photograph was taken.
-There was no photo book or any other book of at-risk for elopement at the receptionist desk.
--The MDS Coordinator would be responsible to create and update this book.
*Resident 3 currently wore AirTags in the soles of her shoes, and it was monitored through an iPad at the nurse desk.
-She confirmed the device would only give resident 3's location and not if she had left the building without staff's knowledge.
-She stated We would be able to track her [location] if she left and I can't speak to its accuracy, it is in the settings if she leaves.
*Resident 3 previously wore a wear tech device, but that was agitating her.
*Regarding resident 3's care plan, administrator A indicated:
-Her care plan was updated to include she was at high risk for elopement, and previously indicated she was at medium risk for elopement.
-The alarm on resident 3's window intervention was due to her threatening to throw her clothes out her window.
*Administrator A confirmed their Elopement, Risk Reduction Strategies, and Management of Missing Residents policy had not been followed.
*Administrator A confirmed:
-Resident 3 had left the facility without staff knowledge through an alarmed door when the resident entered the keypad code that deactivated the alarm.
-The facility was responsible for the safety and supervision of residents.
-Resident 3 was at high risk for elopement and had eloped on several occasions.
Apr 2025
5 deficiencies
2 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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · 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 implement pressure ulcer prevention in...
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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 implement pressure ulcer prevention interventions for one of one sampled resident (1) identified at risk for pressure ulcers who developed a pressure ulcer to her spinal area.
Findings include:
1. Observation on 4/7/25 at 2:48 p.m. of resident 1 in her room revealed:
*She was lying on her back in her bed.
*She was very thin in appearance.
*There were Prevalon boots (cushioned boots used to decrease heel pressure) on the floor next to her closet.
*There was a cushion in the seat of her wheelchair.
2. Review of resident 1's electronic medical record revealed:
*She was admitted on [DATE].
*Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment.
*Her 1/18/25 Braden Scale for Predicting Pressure Sore Risk assessment indicated she was At Risk for the development of a pressure ulcer.
*Her physician orders indicated:
-On 5/22/24 to use pressure relieving mattress on her bed.
-On 11/22/24 to use a pressure relieving cushion in her wheelchair.
-On 11/19/24 a reminder to change the resident's position frequently.
-On 11/7/24 a skin assessment was to be completed weekly.
-On 3/5/25 to off load the resident's heels when she was in bed as needed to prevent skin breakdown.
-On 4/8/25 On open areas of [the] spine area, use wound cleanser, pat dry. APPLY XEROFORM ONLY TO THE OPEN AREAS. Cover [the] area with ABD [abdominal gauze] pad and use soft silicone Tape to apply to the skin. Change daily and PRN. Document wound condition.
-On 4/8/25 STRICT OFFSETTING Q [every] 2 HRS TO KEEP RESIDENT OFF HER BACK. Every 2 hours for Wound injury to spine area.
*Her care plan included:
-Her care plan indicated she had dementia related cognitive impairments, was dependent on staff to assist her with her activities of daily living including bathing, repositioning, dressing, personal hygiene, oral care, bathroom use, and eating set up and received dietary supplement.
-A 1/8/25 revised focus area that she had the potential for pressure ulcer development related to her limited mobility.
--Interventions for that focus area included: encouragement and assistance with the use of assist bars on her bed to assist with turning and repositioning. Education given about importance of offloading pressure, refuses to offload pressure and lay down throughout day, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status, monitor intake and record, pressure relieving cushion to wheelchair and mattress to bed, protect heels from pressure, use padding to help prevent pressure areas, 11/22/24 intervention of Sacral dish cushion placed on [the] backrest [her] of WC [wheelchair] at an elevated position to assist in pressure relief per OT [occupational therapy].
*Her kardex included Sacral dish cushion on backrest of WC at an elevated position to assist in pressure relief per OT.
*A 3/23/25 progress note completed by the dietician revealed resident 1 is a 83 y.o. [year old] female with a BMI of 17 (underweight) that presents with COPD [chronic obstructive pulmonary disease] on a regular diet. Inadequate intake related to decreased appetite as evidence by 50% avg [average] meal completion with wt [weight] change of -5.0% change over 30 days (Comparison Weight 2/19/2025, 104 Lbs [pounds], -12.5%, -13 Lbs). Encourage meal completion of >= [greater than or equal to] 65% and a nutritional supplement BID [twice daily].
-The dietician's progress note did not address past or current skin conditions or the risk for the redevelopment of pressure ulcers.
*Review of Resident 1's skin assessments revealed:
-Her 11/20/24 skin assessment indicated mid spine between the shoulder blades on the boney [bony] prominence she now has an open area that is 2.0 cm [centimeters] x [by] 1.0 cm and she had an alternating pressure relieving mattress on her bed.
-Her 3/5/25 skin assessment indicated she had a slight pink area on the mid upper spine.
-Her 4/8/25 skin assessment indicated, Wound location: Spine, skin trauma/skin tear. Full thickness .total length is 8.0 cm width 2.2 cm and depth 0.1 cm .She has two open areas that are adjoining together. Suspected deep tissue injury on [the] surrounding area.
*Review of the resident's pain assessments in the EMR revealed she was last documented as being assessed for pain on 4/4/25 at 3:12 p.m. when she indicated her pain was 0 on a scale from zero to ten (0-10).
3. Phone interview on 4/8/25 at 1:45 p.m. with resident 1's daughter revealed:
*She felt her mother had taken a turn for the worse.
*Resident 1 did not want to eat by herself and wanted to lie in bed all the time.
4. Interview on 4/8/25 at 3:30 p.m. with licensed practical nurse (LPN) F regarding resident 1 and pressure ulcer prevention revealed:
*LPN F was wound certified and was able to document and initiate treatment for wounds under the guidance of a wound specialist and the resident's physician.
*Resident 1 had a newly identified pressure ulcer on her back along her spine.
*She indicated there were two open skin wounds over the resident's spine with the edges of the skin rolled back and the skin edges were black in color.
*The area surrounding the open wound was dark red to purple which she identified as a suspected deep tissue injury (underlying tissue injury due to prolonged pressure).
*LPN F stated resident 1 preferred to lie on her back and had been noncompliant with the use of wedges for positioning to relieve pressure.
*She had a cushion in the seat of her wheelchair.
*There was no cushion for the back of resident 1's wheelchair that LPN F was aware of.
*Resident 1 did not have a specialized mattress on her bed, but LPN F had requested an alternating pressure relieving mattress be applied to resident 1's bed due to her newly developed pressure ulcer on 4/8/25.
*She had implemented a strict repositioning schedule for resident 1 after that pressure was identified.
*She indicated that when a pressure ulcer was identified she notified the resident's physician, the resident's family and the director of nursing (DON).
*The dietary manager would only be notified if the physician had ordered a dietary supplement.
5. Observation on 4/8/25 at 3:40 p.m. of resident 1 in her room revealed:
*She was lying on her side with the wedge cushion behind her back.
*The bones of her spine could be visualized through her shirt.
*She did not have a specialized mattress on her bed.
*She had Prevalon boots on both feet.
*Her wheelchair had a cushion on the seat of the chair.
*There was no cushion or added protection on the back of her wheelchair.
6. Interview on 4/9/25 at 7:35 a.m. with certified nurse aide (CNA)/certified medication aide (CMA) N regarding resident 1 revealed:
*She was not aware that resident 1 had a pressure ulcer previously.
*She was not aware that resident 1 was to have a sacral dish cushion in her wheelchair to decrease pressure to her back.
*She indicated the only cushion resident 1 used in her wheelchair was the cushion on the seat.
*Staff would reposition her in bed but resident 1 was noncompliant and would often remove the wedge cushion and lie on her back.
7. Interview on 4/9/25 at 8:35 a.m. with CNA/CMA L regarding resident 1 revealed:
*Staff would lay resident 1 down after meals, apply Prevalon boots to her heels and turn her from side to side while she was in bed.
*She indicated the Prevalon boots were a new intervention started about three days ago.
*She indicated resident 1 did not like to be repositioned.
*She was not aware of previous open skin areas to resident 1's back, but stated she had an open area to her buttocks previously.
*She indicated resident 1 previously had a cushion for her back in her wheelchair but it was no longer available.
8. Interview on 4/9/25 at 8:48 a.m. with CNA Q revealed:
*Resident 1 used to have a cushion for her back in her wheelchair.
*Therapy had removed the cushion because she was sliding down in her wheelchair.
*There were no alternate pressure relieving interventions put in place when that cushion was removed.
9. The occupational therapist was not available during the survey for interview related to the sacral dish cushion for the resident's wheelchair.
10. Interview and review of the provider's undated Nursing Skin Care Protocol on 4/9/25 at 12:05 p.m. with DON B revealed she:
*Was aware of resident 1's previous skin issues on her back but was unsure if they were pressure ulcers.
*Indicated she would have to review resident 1's care plan to determine what pressure prevention interventions were in place prior to resident 1's development of her current pressure ulcer on 4/8/25.
*Recalled resident 1 had wedge cushions to be used for repositioning in bed but resident 1 had been noncompliant with the use of them.
*Expected if the sacral dish cushion was in her care plan to decrease pressure to her back, the staff should have followed the resident's care plan.
*Was not aware that staff were no longer using the sacral dish cushion when the resident was in her wheelchair.
*Expected the charge nurse to request an occupational therapy evaluation if it was determined the current interventions were needed to be changed related to the sacral dish cushion.
*Indicated the Nursing Skin Care Protocol was the policy the facility used related to skin issues and pressure ulcers.
*Stated, after reviewing the Nursing Skin Care Protocol, the protocol was not up to date and did not reflect the provider's current process.
-She believed the process on the Nursing Skin Care Protocol was prior to the implementation of the EMR.
11. Review of the provider's undated Nursing Skin Care Protocol revealed:
*All skin care issues require the assessment of the resident's overall clinical status using the following guide.
-1. Complete the skin assessment tool (Braden) and communicate the results in a Progress note (under skin/wound note) with notification to the CNA with guidance for turn reposition if indicated.
-2. Assess the skin care issue and document findings in the progress notes (under skin/wound note).
-3. Review causative factors and implement preventative/pressure relief devices if indicated. (document in skin/wound note)
-4. PCP [primary care provider] notification of skin care issues and obtain treatment order. DO NOT classify an ulcer as pressure without PCP consultation. (document notification in skin/wound note)
-5. Notify DON, Dietary Manager, and MDS [Minimum Data Set] Coordinator of skin care issues via email. (document notification in skin/wound note)
-6. Recommended appropriate diet changes: Registered Dietician will perform a nutritional needs needs assessment/ (document notification skin/wound note)
-7. Review resident's pain level (pain tool) and implement/revise/continue and individualized pan [pain] management program. (document pain level in skin/wound note)
-8. Notify family/responsible person with condition changes. (Document notification in skin/wound note)
-9. Daily and weekly narrative documentation is required (see criteria and examples for each.) Skin sheets will be completed if:
a. The resident has a significant bruise
b. The resident has an open wound or skin tear
c. The resident has a suspected deep tissue injury
d. The resident has any skin issues requiring follow-up or treatment
-10. Document education given to family/resident and response to the education.
-11. Notify PCP and family/resident at 14 days s/p [status post] no response to treatment. Change in treatment plan may be indicated if not improvement is observed. (Document notifications in the progress note under skin/wound note.)
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
Deficiency F0760
(Tag F0760)
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...
Read full inspector narrative →
**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 one of one sampled resident (1) was free from a significant medication error that involved a controlled medication (medications with risk for abuse and addiction) that she did not have orders to receive. She required an emergency room (ER) evaluation and treatment related to a change in her condition.
Findings include:
1. Review of the provider's 3/25/25 SD DOH FRI regarding resident 1 revealed:
*Staff found resident 1 unresponsive, shaking, with a weak pulse and a blood pressure of 81/47.
-She was transported to the ER by ambulance.
*A drug screen was performed at the ER.
-The drug screen indicated resident 1 had a benzodiazepine (sedative) medication in her system.
-Resident 1 was not on a prescribed benzodiazepine medication.
*Resident 1 was returned to the facility via ambulance on 3/25/25 at 4:00 p.m.
*The provider did not identify when or how resident 1 received a benzodiazepine that was not prescribed to her.
Administrator A, licensed practical nurse (LPN) H, and registered nurse (RN) I had completed the investigation for the SD DOH FRI, but were not available for interview.
2. Review of resident 1's electronic medical record (EMR) revealed:
*She was admitted on [DATE].
*Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment.
*Her diagnoses included: Chronic Obstructive pulmonary disease, hypertension, hypo-osmolality and Hyponatremia, constipation, insomnia, emphysema, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, respiratory failure, osteoporosis, atelectasis.
*Her physician orders indicated the medications she was prescribed were:
-Calcium-Vitamin D Tablet 600-400 MG-UNIT [milligrams-unit] (Calcium Carb-Cholecalciferol) Give 1 tablet by mouth two times a day.
-Fluticasone-Umeclidin-Vilant Aerosol Powder Breath Activated [inhaler used to treat breathing issues] 100-62.5-25 MCG/INH [micrograms/inhalation] 1 puff inhale orally one time a day
-Psyllium Husk Powder Give 1 Tbsp [tablespoon] by mouth one time daily for constipation.
-Citalopram Hydrobromide [anti-depressant medication] Oral Tablet 10 MG Give 10 mg by mouth one time a day related to ANXIETY DISORDER.
*Resident 1's EMR indicated she was to receive her medications whole.
*According to resident 1's medication administration record (MAR) on 3/25/25 at 8:08 a.m. resident 1 received her Calcium-Vitamin D tablet, citalopram, psyllium husk powder, and her inhaler from certified nurse assistant/ certified medication aide (CNA/CMA) N.
Review of resident 1's progress notes revealed:
*On 3/25/25 at 10:35 a.m. licensed practical nurse (LPN) F was called to the activity room where she witnessed resident 1 shaking, having almost seizure like activity. Non responsive. Vitals taken, O2 sats [oxygen saturation] dropping. BP [blood pressure] 81/47. Arms limp. Pupils fixed non reactive. Shallow breathing. Sudden onset.
*On 3/25/25 at 10:37 a.m. LPN F documented in a progress note, Ambulance called and hospital called.
*Resident 1 left in the ambulance at 11:02 a.m. with emergency medical services (EMS) staff.
*On 3/25/25 at 3:38 p.m. Received report from ER, She [resident 1] was found to have benzodiazepines in her system. She continues to be very lethargic and unable to sit up in [a] wheelchair, she was sent back to the facility via ambulance. She is on oxygen via NC [nasal cannula] and [an] order has been placed to monitor resident status and vitals hourly until she returns to baseline, it is possible that she will return to baseline by morning per the ER staff. They gave her a 500ml [milliliter] bolus and has been on a normal saline drip [intravenous fluids]. She continues on Bactrim [antibiotic] for 2 more administrations. Her sodium is low at 121- they are not going to do anything to treat it, daughter [name] was in the ER with her and was in agreement with that. She is back in the facility since 1500 [3:00 p.m.]. She arrived back via ambulance in [a] hospital gown, they cut her clothes off of her upon arrival to the ER. Her vitals are stable, O2 [oxygen] 91% on 4L [liters] via NC, BP 153/66, HR [heart rate] 91, T [temperature] 97.6 [degrees Fahrenheit]. She is in bed sleeping at this time.
Review of the 3/25/25 ambulance report regarding resident 1 revealed:
*Resident 1 was foaming [at the] mouth on sight.
*Her oxygen was increased from 2L to 4L.
*Her pupils were nonreactive to light.
*Her skin was cold to the touch.
*At 11:19 a.m. resident 1 opened her eyes.
*At 11:23 a.m. resident 1 moans/groans.
*They arrived at the hospital with resident 1 at 11:25 a.m.
Review of the 3/25/25 emergency room Note regarding resident 1 revealed:
*EMS had reported oxygen saturations (O2 level in blood) between 50% and 70%.
*During the assessment in the emergency room resident 1 withdrew from painful stimuli and as the examination progressed, she became more alert.
*She began to smile and attempt to answer questions.
*Physical examination noted Patient appears obtunded [slowed responses and not alert].
*Resident 1's urine drug screen was positive for benzodiazepines.
*Her problem list indicated Drug ingestion, accidental.
*The emergency department plan indicated It does appear she has ingested a benzodiazepine. Not on her medical record. Administration at [the] nursing facility was advised and are investigating/reporting [the] medication error resulting in [the] hospital visit.
Review of resident 1's 3/26/25 repeat urine drug screen revealed she had tested positive for
benzodiazepines.
3. Review of records regarding residents who resided at the facility with a physician's order for a benzodiazepine medication revealed:
*There were six residents prescribed benzodiazepines.
-Two of those residents were prescribed clonazepam (a controlled medication used to treat anxiety).
-Four of those residents were prescribed lorazepam (a controlled medication used to treat anxiety).
*Two residents were documented as having received their ordered benzodiazepine medication in the morning of 3/25/25 as follows:
-Resident 2 received lorazepam at 7:36 a.m. on 3/25/25.
-Resident 3 received clonazepam at 8:03 a.m. on 3/25/25.
4. Interview on 4/7/25 at 4:33 p.m. with certified nursing assistant (CNA)/certified medication side (CMA) N revealed:
*On 3/25/25 at 8:08 a.m. she had crushed resident 1's medications, put them in pudding, and administered them to her in the dining room.
*She indicated resident 1 was fine at that time.
*At approximately 10:00 a.m. activities director O came out of the activity room to alert staff of a change in resident 1's condition.
*CNA/CMA N responded with LPN F to the activity room where resident 1 was noted to be unresponsive, her face was gray, and her lips were blue.
*CNA/CMA N was unable to feel a pulse in resident 1's wrist. LPN F was able to feel a pulse in resident 1's neck.
*Resident 1's oxygen was on.
*LPN F performed a sternal rub (firmly rubbing the breastbone with knuckles to assess response) with no response from resident 1.
*CNA/CMA N stated she knew she had not given resident 1 a benzodiazepine because resident 1 was not near anyone who received a benzodiazepine at the time her morning medications were administered to her.
*She indicated she did not know how resident 1 could have taken a benzodiazepine unless the night nurse had given her someone else's medication.
5. Interview on 4/7/25 at 4:47 p.m. with activities director O revealed:
*On 3/25/25 resident 1 was in the activity room while other residents played Yahtzee (a dice game) after breakfast.
*Activities director O stated that resident 1 usually played Yahtzee but had not that day or a couple of days prior.
*There was no food or drink in the activity room during that time.
*Activities director O stated she was alerted by another resident that resident 1 had tightened up.
*Once she saw resident 1, she went out to the nurse's station to get help from the nurse.
6. Interview on 4/8/25 at 8:17 a.m. with LPN F revealed:
*She was the charge nurse on 3/25/25 when resident 1 was sent to the ER.
*She stated when she saw resident 1 in the activity room the resident was shaking, her lips were blue, her blood pressure was low, her pulse varied, her oxygen saturations were low, her fingers were blue, and her pupils were pinpoint in size and did not react to light.
*Staff assisted resident 1 to her room to lie her down and the ambulance was called and transported her to the ER.
*The hospital later called with a report and informed the facility staff that resident 1 had tested positive for benzodiazepines in her urine.
*During the investigation of that incident RN I asked LPN F about medications having been brought in by a visitor and given to resident 1.
*LPN F indicated the only visitor resident 1 had was her daughter and she had not been in the facility since the Thursday prior [3/20/25].
*LPN F stated resident 1's room was searched for medications, and none were found.
*LPN F indicated RN I and LPN H had not reviewed the controlled medications in the medication carts after the facility staff were notified that resident 1 had tested positive for benzodiazepines.
*LPN F indicated she was not sure how resident 1 had received a benzodiazepine but it could have possibly been a medication error.
*When asked about resident 1's mealtime tablemates she stated resident 1 sat with one other resident, resident 4, and resident 4 was not prescribed a benzodiazepine medication.
7. Interview on 4/8/25 at 9:50 a.m. with environmental services staff K revealed:
*She had, at times, found medications in residents' rooms when she cleans the rooms.
*When she found a medication, she took it to the charge nurse.
8. Interview on 4/8/25 at 9:55 a.m. with doctor C revealed he:
*Was resident 1's primary physician.
*Was aware of resident 1's unresponsive episode on 3/25/25 that resulted in an ER visit where she tested positive for benzodiazepines.
*Verified Citalopram or any of the resident's other prescribed medications would not have caused a false positive benzodiazepine level in the urine.
*Verified resident 1 did not have an impaired liver or kidneys that may alter the absorption or elimination of a benzodiazepine.
*Reviewed the ambulance report and indicated none of the staff on the ambulance during resident 1's transfer to the ER were able to administer medications.
*Indicated that the ambulance does not have a benzodiazepine available in its medication box.
*Indicated resident 1's sodium level alone would not have caused the symptoms that she had that day.
*Felt resident 1 had a reaction to a medication she was not supposed to have received.
9. Interview on 4/8/25 at 1:45 p.m. with resident 1's daughter revealed:
*The nurse practitioner (NP) at the hospital ER had told her, Someone gave her a sedative.
*She stated the NP told her she was going to report the incident because mistakes could happen, but this mistake should not have happened.
*She did not know how her mother could have gotten a medication she was not prescribed.
*She did not feel her mother would ever willingly take another resident's medications because she did not like taking medications.
*She felt her mother had declined since she was sent to the ER on [DATE].
10. Interview on 4/8/25 at 1:59 p.m. with consultant pharmacist E revealed:
*He confirmed resident 1 was not prescribed a benzodiazepine.
*Resident 1 was not prescribed a medication that would have resulted in a positive for a benzodiazepine in her urine
*He indicated lorazepam would start taking effect in about 15 to 40 minutes after administration and the effects would last about six hours.
*Clonazepam would start taking effect in about 30 to 40 minutes after administration and the effects would last up to a day later.
*He did not think the medication had been administered the night before because of the time of the onset of resident 1's symptoms.
Continued interview on 4/8/25 at 4:07 p.m. with consultant pharmacist E revealed:
*He felt lorazepam was more likely to have been the benzodiazepine ingested by resident 1 rather than clonazepam due to the length of time the symptoms lasted.
*He stated he had reached out to a laboratory, and they had indicated clonazepam, and lorazepam could remain detectable in the resident's urine for one to five days after ingestion.
*After he reviewed resident 1's urine drug tests, he felt there had been one or very few administrations of the benzodiazepine because of the amount of time resident 1 remained positive.
11. Interview on 4/9/25 at 11:13 a.m. with director of nursing (DON) B revealed:
*She was not in the facility on 3/25/25 but did provide phone consultation to administrator A and RN I related to resident 1's event.
*When she was notified of the incident, she advised RN I to be sure resident 1 had not received another resident's medication.
*DON B sent administrator A a list of medications that may cause a false positive for benzodiazepines in a urine drug screen.
*She advised administrator A and RN I to consult a pharmacist regarding resident 1's event.
*She indicated, although resident 4 did not have a prescribed benzodiazepine, resident 1 was moved from her table in the dining room because resident 4 liked to share her food and they wanted to be sure there was no chance that resident 1 could have received something from her.
*Resident 4 was the only resident at the breakfast table with resident 1's on 3/25/25 and there were no other residents at nearby tables that were prescribed a benzodiazepine medication.
*DON B reported resident 1's room was searched while resident 1 was in the ER and there were no medications found.
*She indicated they were not able to identify how resident 1 could have taken or been given a benzodiazepine.
-The possibilities that were identified included a family member, the hospital staff, the ambulance staff, or a medication error by the facility staff, but those were all speculation.
*She agreed that a resident receiving a benzodiazepine that was not prescribed for that resident is a medication error.
*She indicated administration had not investigated the time between resident 1 receiving her morning medications and the onset of her symptoms to determine the potential time the resident would have received the medication.
*She stated that they had concluded the onset of symptoms was variable after their discussion with the pharmacist during their investigation.
12. Review of the provider's undated Medication Administration- Required and Critical Performance Criteria policy revealed:
*The CMA will administer oral .medications utilizing the following criteria.
-1. Check the Medication Administration Record (MAR) against the physician orders as recommended by the facility.
-4. Perform 3 checks on each medication.
-8. Safely administer medications to resident utilizing the 7 rights of administration
--a. Right drug
--b. Right dose
--c. Right patient/resident
--d. Right route
--e. Right time
--f. Right technique
--g, Right documentation
-9. Ensure that all oral medication as offered is swallowed by the resident.
Review of the provider's undated Medication Error Reporting policy revealed:
*Includes:
-Wrong Medication
-Wrong Person
-Wrong Dose
-Wrong Route
-Missed Medication
Review of the provider's undated Medication Management Policy revealed:
*Medications will be administered to residents as prescribed.
*Medications are administered in accordance with written orders of the attending physician or physician extender.
*Residents are identified before medication is administered. Methods of identification include:
-a. Checking photograph attached to medical record.
-b. Asking a resident to say and/or spell his/her name.
-c. If necessary, verify resident identification with other facility personnel.
*Medications supplied for one resident are never administered to another resident.
*The resident is always observed after administration to ensure that the dose was completely ingested.
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 review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), observation, record...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), observation, record review, interview, and policy review, the provider failed to ensure a thorough investigation was completed and reported to the SD DOH regarding a facial bruise of unknown origin for one of one sampled resident (1).
Findings include:
1. Review of the provider's 3/25/25 SD DOH FRI regarding resident 1 revealed:
*On 3/25/25 at 10:30 a.m. in the activity room resident 1 was found unresponsive, shaking, with a weak pulse and a blood pressure of 81/47.
-She was transported to the emergency room by ambulance.
*The emergency department performed a drug screen.
-The drug screen indicated resident 1 had a benzodiazepine medication in her system.
-Resident 1 was not on a prescribed benzodiazepine medication.
*The SD DOH FRI did not indicate resident 1 had any injuries or bruises.
Observation on 4/9/25 at 8:45 a.m. of resident 1 at the breakfast table revealed:
*She was seated in a wheelchair.
*A purple/yellow/green skin discoloration was noted just to the left of the center of her forehead that measured approximately 3 centimeters (cm) by 3 cm.
Review of resident 1's electronic medical record revealed:
*She was admitted on [DATE].
*Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment.
*Her diagnoses included: chronic obstructive pulmonary disease (disease that restricts breathing), insomnia, emphysema (lung condition that causes shortness of breath), dementia without behavioral disturbance, psychotic disturbance (altered reality/thoughts), mood disturbance, anxiety, and respiratory failure.
*Her care plan included:
-A 10/28/24 focus area that indicated she was dependent on staff for meeting her physical needs related to cognitive deficits.
-A 7/29/22 focus area that indicated she needed staff assistance with her activities of daily living.
--Interventions for that focus area included she needed the assistance of a staff member for her bathing/showering, repositioning, dressing, personal hygiene/oral care, use of a toilet, and assistance with setup for eating.
-A 10/28/24 focus area indicated that she had impaired cognition related to dementia.
Review of resident 1's nurse progress notes revealed:
*On 3/25/25 a note indicated Resident continues to have increased confusion. Resident was in bed calling out stating she was falling. Resident constantly taking of [off] oxygen tubing and using it as thread for sewing. Resident noted to have a bruise to the forehead. Resident assisted to bathroom with can [certified nursing assistant] report [of the resident having said] 'let me put on my new ankles.'
-There was no additional information that indicated an assessment, or investigation was completed regarding the bruise on her forehead.
*On 3/29/25 she was found on the floor in her room.
-She had a bruise and bump on her left elbow.
*On 3/29/25 her daughter was notified of the 3/29/25 fall and POA questioned about bruising on her forehead. This nurse researched through the notes. Notes read to POA.
*On 3/29/25 a note indicated Review of resident 1's 3/25/25 ambulance transport report revealed it was noted that she had a 1 x 1 [one by one] square bruising above [her] left eye.
Review of resident 1's 3/25/25 emergency room visit report revealed Noted small bruise to the forehead and a couple to her shins.
Review of resident 1's skin assessments completed on 3/26/25 and on 4/2/25 had not indicated a bruise on her forehead.
Interview on 4/7/25 at 4:33 p.m. with certified nurse aide/certified medication aide (CNA/CMA) N revealed:
*She noticed the bruise on resident 1's forehead a few days ago.
*She believed the bruise was from resident 1's fall on 3/29/25.
Interview on 4/8/25 at 3:05 p.m. with director of nursing B regarding resident 1's forehead bruise that was identified as a bruise on 3/25/25 revealed:
*She was not notified or aware of resident 1's forehead bruise.
*She did not think administrator A had been notified of the bruise.
*There was no investigation completed to identify a potential cause of the bruise.
*She stated she had previously provided education, on various occasions, with staff regarding reporting resident injuries.
Interview on 4/9/25 at 7:35 a.m. with CNA/CMA N revealed:
*She would report any signs of abuse, bruises, skin issues, and resident concerns to the charge nurse.
*If the charge nurse did not respond to her concerns, she would report her concern to the director of nursing or the administrator.
Interview on 4/9/25 at 8:35 a.m. with CNA/CMA L revealed:
*She would report any concerns such as bruises, skin issues, and resident concerns to the charge nurse.
*She noticed the bruise on resident 1's face in March but did not recall what day.
*She indicated she did not report the bruise to the charge nurse because she was told in shift report that the previous CNA had notified the charge nurse.
Interview on 4/9/25 at 8:48 a.m. with CNA Q revealed:
*He noticed the bruise on resident 1's forehead the day after she fell on 3/29/25.
*He would report anything out of the ordinary for a resident to the charge nurse.
-He verified that included skin issues, changes in condition, and resident concerns.
Interview on 4/9/25 at 9:50 a.m. with director of nursing B revealed there was no documentation to verify when or what resident information was passed on by staff during the nurse shift report.
Administrator A was not available for an interview during the survey.
Review of the provider's undated Reporting Abuse to Facility Management policy revealed:
*Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
*Reports of any suspected abuse or incidents of abuse must immediately be reported to the Social Services Director, Administrator, and the Director of Nursing. In the absence of those listed above, such reports may be made to the Nurse Supervisor on duty.
*The Administrator, Social Services Director and Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator, Social Service Director and/or Director of Nursing must be called and informed of such incident.
*When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy.
*A completed copy of documentation forms and witness statements, if any, must be provided to the Administrator within 24 hours of the occurrence of an incident of suspected abuse. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator within 5 working days of the occurrence of such incident.
*Upon receiving information concerning a report of abuse, the Director of Nursing will request that Social Services monitor and document the resident's reactions to statements regarding the incident and their involvement in the investigation.
*Unless the resident requests otherwise, the Social Service Director will give the Administrator and the Director of Nursing a written report of their findings.
Review of the provider's undated Abuse Investigation policy revealed the following:
*All reports of resident abuse, neglect, injury of unknown source and misappropriation of resident property shall be promptly and thoroughly investigated by facility management.
*The individual conducting the investigation will, as [at] a minimum:
-a. Review the completed documentation form
-b. Review the resident's medical record to determine events leading up to the incident
-c. Interview the person(s) reporting the incident
-d. Interview any witnesses to the incident
-e. Interview the resident (as medically appropriate)
-f. Interview the attending physician as needed to determine the resident's current level of cognitive function and medical condition
-g. Interview staff members who have contact with the resident during the period of the alleged incident
-h. Interview the resident's roommate, family members, and visitors as needed
-i. Interview other residents to whom the accused employee(s) provides care or services for
-j. Review all events leading up to the alleged incident.
*Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports.
*The results of the investigation will be recorded on approved documentation forms.
*The Administrator or his/her appointed member of management will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the Local Policy Department, the Ombudsman and others as may be required by state or local laws, within (5) working days of the reported incident.
Review of the provider's undated Mandatory Reporting policy revealed the following:
*Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
*Willful means the individual intended the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish.
*Do an investigation, review the findings, and revise the care plan as necessary.
*Do an investigation and report per the appropriate timeline.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), record review, obse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), record review, observation, and interview, the provider failed to follow professional standards to ensure a resident's physician ordered:
*Fluid restriction was implemented effectively and accurately documented for one of one sampled resident (1).
*Basic metabolic panel (BMP) laboratory (lab) test (a common blood test that measures levels of key electrolytes including sodium, glucose, and kidney function indicators) was not completed for one of one sampled resident (1) who had been diagnosed with a low sodium level (hyponatremia).
Findings include:
1. Review of resident 1's electronic medical record revealed:
*She was admitted on [DATE].
*Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment.
*Her diagnoses included: hypertension (high blood pressure), hypo-osmolality (a condition where bodily fluids have a lower-than-normal concentration of solutes, such as sodium and other electrolytes), and hyponatremia (low sodium), constipation, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
*She had physician orders:
-On 5/3/24 to be given Arginaid supplement every day and evening shift.
-On 10/29/24 to be weighed twice weekly on Wednesdays and Saturdays.
-On 3/26/25 to be placed on a fluid restriction of 40 ounces (oz) or 1200 cubic centimeters (cc) per day for her low sodium level.
-On 3/25/25 a BMP lab (a basic metabolic panel, a common blood test that measures levels of key electrolytes including sodium, glucose, and kidney function indicators that was to be completed on 3/31/25.
*Her care plan indicated she had dementia related cognitive impairments, was dependent on staff to assist her with her activities of daily living including bathing, repositioning, dressing, personal hygiene, oral care, bathroom use, and eating setup and received a dietary supplement.
*Her fluid intake documentation included the following fluid intake amounts:
-On 3/26/25 a total of 240 cc.
-On 3/27/25 a total of 540 cc.
-On 3/28/25 a total of 260 cc.
-On 3/29/25 a total of 450 cc.
-On 3/30/25 a total of 380 cc.
-On 3/31/25 a total of 400 cc.
-On 4/1/25 a total of 240 cc.
-On 4/2/25 a total of 800 cc.
-On 4/3/25 a total of 730 cc.
-On 4/4/25 a total of 190 cc.
-On 4/5/25 a total of 330 cc.
-On 4/6/25 a total of 300 cc.
*Those were all below her daily allowed fluid amount of 1200 cc.
Observation on 4/9/25 at 8:45 a.m. of resident 1 at the breakfast table revealed:
*She had an almost empty coffee cup and a half-empty glass of juice on the table in front of her.
*She required staff to cue her to eat and drink.
Observation on 4/8/25 at 3:40 p.m. of resident 1's over-the-bed table in her room revealed:
*A half empty glass of orange juice.
*A half empty pitcher of water without ice.
Observation on 4/9/25 at 7:35 a.m. of resident 1's room revealed two unopened individual-sized containers of Jello on her bedside table.
Interview on 4/8/25 at 1:44 p.m. with resident 1's daughter revealed resident 1 took a drink made up with something so her bed sores heal.
Interview and record review on 4/8/25 at 2:51 p.m. with certified nursing assistant (CNA)/certified medication aide (CMA) N revealed:
*She was aware of three residents who had fluid restrictions, resident 1 was one of the three.
*Residents who required fluid restrictions had a physician order for the specific restriction.
-Activity staff members would know [which residents had fluid restrictions].
-Dietary staff members would know [which residents had fluid restrictions], as [those residents were] only allowed so much [fluids] at breakfast, lunch, and supper.
-Nursing did not document any fluids consumed by residents on fluid restrictions as they only give enough [fluid] to swallow [the] medication.
*Staff were alerted to which residents were on fluid restrictions at staff huddles (meetings).
*She thought resident 1 was on a 1500 cc fluid restriction.
-She reviewed resident 1's EMR and then stated, She is on 40 ounces, 8 ounces with each meal and two 8 ounces outside of meals.
Interview on 4/8/25 at 3:12 p.m. with dietary manager G regarding residents' fluid restrictions revealed:
*The cooks were to document the resident's fluid intake during mealtimes.
*CNA's were to document the residents' fluid intakes when they collect water pitchers, they measure [the amount consumed] and document.
*Activities staff were to document consumed fluid amounts for residents on fluid restrictions also.
Interview on 4/9/25 at 8:35 a.m. with CNA/CMA L revealed:
*The water pitchers were passed to the resident rooms at 4:00 a.m. and 2:00 p.m.
*The CNAs were responsible for documenting residents' fluid intakes not consumed at meals in the residents' EMR.
*She was aware resident 1 was on a fluid restrictions since she returned from her most recent hospitalization.
*Water pitchers were not to be provided to residents on a fluid restriction.
*The nurses should have informed the CNAs how much fluid a resident may receive when on a fluid restriction.
*Resident 1 received a supplement at 10:00 a.m. and it was to be documented as fluid intake in the EMR by the nurse.
*She was not aware that Jello should be counted as a fluid, she indicated she documented Jello as a snack.
Interview on 4/9/25 at 8:48 a.m. with CNA Q revealed:
*If a resident was on a fluid restriction he would limit the resident's fluid intake.
*He indicated resident 1 was on a fluid restriction.
*When a resident was on a fluid restriction a water pitcher should not be provided in the resident's room.
*He documented a resident's fluids intake consumed outside of meals in the resident's EMR.
Interview on 4/9/25 at 9:39 a.m. with CNA/CMA N revealed:
*Resident 1's Arginaid supplement was documented on the treatment administration record (TAR).
*The nurse on duty was responsible for completing the TAR documentation.
Interview on 4/9/25 at 9:50 a.m. with director of nursing (DON) B revealed:
*Resident 1's fluid restriction information was passed on to staff during the nursing shift report.
*There was no documentation to verify when or what resident information was passed on during those nurse shift reports.
-Resident 1's 3/25/25 physician ordered BMP lab that was to be completed on 3/31/25 was not completed as ordered.
Interview on 4/9/25 at 10:35 a.m. with licensed practical nurse (LPN) F revealed:
*The nurses were responsible for completing the TAR documentation.
*The kitchen would bring resident 1's Arginaid supplement to the nurse's station and the CNAs would distribute the supplement to the resident.
-The nurses would document that the Arginaid was administered to the resident in their EMR, but the nurses would not administer it or document how much the resident drank.
-The CNAs were responsible for documenting the resident's fluid intake that resulted from the administration of the supplement in the EMR.
*She verified the nurses would document on the fluid restriction order in the resident's TAR.
-She indicated that documentation of the resident's fluid restriction in the TAR was the nurse's acknowledgement that the resident was on the fluid restriction not that the nurse had monitored the resident's fluid intake.
*It was her expectation that a resident on a fluid restriction only received a partial pitcher of water in the resident's room.
Interview on 4/9/25 at 10:40 a.m. with CNA/CMA N revealed:
*Resident 1 did not have a designated task in the EMR to document the amount she consumed of her Arginaid supplement.
*She verified not all fluid intake was documented in the resident's EMR.
*She verified CNA documentation of resident's fluid intake was inconsistent and on some days there was no CNA charting of resident fluid intakes.
*She indicated a resident on a fluid restriction should not have a pitcher of water in the resident's room.
*She stated there was no way for a CNA to know how much fluid intake a resident had consumed in order to determine if the resident had exceeded the maximum ordered fluid intake allowed for the day.
A fluid restriction policy was requested from DON B but was not provided by the end of the survey.
CONCERN
(E)
📢 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 F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on record review, interview, and policy review, the provider failed to ensure medications were securely stored and inaccessible to unauthorized individuals including:
*Two of two unauthorized in...
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Based on record review, interview, and policy review, the provider failed to ensure medications were securely stored and inaccessible to unauthorized individuals including:
*Two of two unauthorized individuals (administrator A and maintenance director M) who had access to one of one medication room where controlled medications (medications at risk for abuse and addiction) were stored in an unsecured manner.
*One of one certified nursing assistant (CNA)/certified medication aide (CMA) N who had not securely stored the keys to one of two medication cart and a drawer where controlled medications were stored for two of two observations.
Findings include:
1. Observation on 4/7/25 at 2:40 p.m. of the medication carts near the nurse's station revealed:
*The keys to open one of the two medication carts were stored on an open shelf on the side of the medication cart beside the water cups.
-Those were accessible to visitors and unauthorized individuals.
*There was no staff member present within sight of the medication carts.
Interview on 4/7/25 at 2:43 p.m. with CNA/CMA N revealed:
*She had left the keys on a shelf on the medication cart.
*She verified those keys opened the north wing medication cart and that key ring also contained the keys to open the drawer where the controlled medications were stored.
*She indicated it was not her normal practice to leave those keys unattended on the medication cart.
*She indicated she usually kept the keys in her pocket.
*She verified the keys were accessible to anyone when they were stored on an open shelf on the side of the medication cart.
Observation on 4/8/25 at 8:36 a.m. of a medication cart in the west hallway revealed it was unlocked and there were no staff members in sight of the medication cart.
2. Observation on 4/7/25 at 2:57 p.m. of the medication room with licensed practical nurse (LPN) J revealed:
*The medication room was secured with a coded keypad on the door.
*The refrigerator in the medication room was not locked.
*In the unlocked refrigerator there was a lock box that contained a bottle of liquid lorazepam (a controlled anti-anxiety medication).
*That lock box in the refrigerator was not locked.
3. Interview on 4/7/25 at 4:33 p.m. with CNA/CMA N revealed the nurses, CMAs, administrator, and maintenance staff knew the code to enter the medication room where medications were stored.
4. Interview and observation on 4/8/25 at 8:17 a.m. with LPN F in the medication room revealed:
*She indicated the nurses, CMAs, administrator, and maintenance staff knew the keypad code to enter the medication room where medications were stored.
*She stated the code to the medication room had been changed one time, by maintenance, because the keypad needed to be changed. Prior to that the code was the same for years.
*During the interview with LPN F, maintenance director M entered the medication room with the use of the keypad door code.
*LPN F indicated maintenance director M previously had been in the medication room without the nursing staff being aware he was in there.
*LPN F removed the lock box from the unlocked refrigerator in the medication room.
*She verified the lock box was not locked, and that it contained lorazepam.
5. Interview on 4/9/25 at 7:30 a.m. with maintenance director M revealed:
*He had changed the keypad codes to other doors within the facility but had never changed the code to the medication room's keypad.
*He knew the keypad code to enter the medication room.
*He went into the medication room to deliver pop for a resident, run water in the sink drain, and complete any maintenance required in the room.
*He at times was in the medication room without another staff member present.
6. Interview on 4/9/25 at 11:39 a.m. with director of nursing (DON) B revealed:
*She verified the nurses, CMAs, administrator A, and maintenance director M had access to the medication room where medications were stored.
*Maintenance director M had keys to all the doors in the building, including the medication room, in case there was a fire, an emergency, or he needed to work on something such as plumbing or electricity.
*She indicated administrator A also had access to every room in the facility.
*DON B agreed administrator A and maintenance director M would have access to medications that were stored in the medication room.
*She stated that the medications stored in the medication room were to be locked or in a medication cart except for the stock medications.
*She indicated administrator A and maintenance M should not have access to controlled medications.
*She was aware that the refrigerator in the medication room was not locked.
*She was not aware that the lock box for controlled medications in the refrigerator was not locked.
*She expected that lock box to be locked in order to secure the controlled medications from unauthorized access.
*It was her expectation that the keys for the medication carts would be in the CMAs' or nurses' pocket or locked in the medication cart to prevent access from unauthorized individuals.
*She would not expect the keys to be left unattended on an open shelf on the medication cart.
7. Review of the provider's undated Proper Storage, Usage and Documentation of Narcotics [controlled medications] policy revealed Access to narcotic is to be by a licensed staff and Director of Nursing ONLY!
Review of the provider's undated Medication Storage and Labeling policy revealed Medications and biologicals will be stored in locations accessible only to designated staff.
Review of the provider's undated Medication Management policy revealed:
*During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse.
*The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
Mar 2025
21 deficiencies
CONCERN
(D)
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 record review, interview, and policy review the provider failed to ensure a thorough investigation was completed regard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the provider failed to ensure a thorough investigation was completed regarding an allegation of abuse for one of one sampled resident (5).
Findings include:
1.Review of a 12/25/24 grievance form completed by registered nurse (RN) Q regarding resident 5 revealed:
*The nature of the grievance was Resident reports CNA [certified nursing assistant] R used unnecessary force and maleficence [harmful] while giving cares in changing her brief and providing peri-care during repositioning/turning.
*The incident was documented attached to the grievance as happening between 7:30 a.m. and 8:00 a.m. on 12/25/24.
*RN Q's documentation attached to the grievance stated, Upon entering [the] resident's room she was visibly upset, looking to me and stating, 'I don't know what else to do. I know I can trust you to make this right.' She then reported the following:
- CNA R was in resident 5's room completing morning cares and resident 5 was lying on her right side holding onto the bed rail facing the wall.
-Resident 5 then reported to RN Q, that CNA R was short and mean with her, using a 'mean voice', and telling her to roll over. 'The way she was doing it, I couldn't brace myself enough on the bed handle (side rail). She was pushing me too hard and I told her to stop because I felt like I was going to fall between the wall and the bed. I was scared. She wouldn't listen to me when I told her to stop.' Resident [resident 5] is crying at this time, recalling her fear at falling from the bed and the aide not listening to her to her pleas to stop pushing.
-Resident 5 continues to cry, 'Please have someone else help me to the dining room. I could have been on the floor. I'm so scared. She scares me. I don't want her to come near me.' Resident [resident 5] later reports to me [RN Q], 'I don't feel safe with her [CNA R]. I choose not to have her [CNA R] care for me. Ever.'''
*On 12/26/24 RN Q spoke with CNA R in a private location. CNA R denied wrongdoing and curtly [abruptly] tells this nurse [RN Q], 'I did nothing wrong. I was only pushing her [resident 5] to her side and she wasn't helping. I was told she gets emotional.' CNA R has an attitude in responding to my questions, not allowing for constructive critique or approach in working with [resident 5].
*RN Q documented her evaluation of CNA R which included RN Q felt CNA R had fluctuations in presentation from being kind and helpful to angry and short-tempered.
*DON B documented on the grievance form that on 12/27/24 the grievance had been resolved and CNA [CNA 5] agency asked to coach CNA- noted improvement by staff.
2. Review of an email dated 12/27/24 from DON P to DON B and administrator A revealed:
*DON P was in the facility on 12/25/24 and stated she had addressed the issues that had occurred on that day, and she had placed the grievance form in administrator A's box in the office.
*Her documentation in the email included:
-I know these two have not gotten along but there is feedback coming from permanent and travel staff that her [CNA R] attitude is not good, she does not take suggestions and criticism well, and she is rough with the residents. None of the accounts that occurred on Christmas Day were witnessed by other staff members as she likes to work independently as well.
-On Christmas day she [CNA R] was switched to a different group because [resident 5] said she was scared of her, [another resident] also complained, and I believe [an additional resident] mentioned something as well. All [complaints] determined not to be abuse but concerns [were] present. Yesterday she was also changed off that group to a different group just to have some time to follow up with the grievance and see if changing [the group] seems to help overall. With the admission and readmission yesterday, it was a bit busy prior to me leaving so I did not have much of a chance to deal with this outside of [CNA/CMA K] working on getting ahold of [a travel nursing agency].
3. Review of resident 5's electronic medical record (EMR) revealed:
*She was admitted on [DATE].
*Her 12/26/24 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact.
*The first skin observation tool assessment completed after the 12/25/24 reported incident was documented on 1/10/25, with no skin issues documented.
*A psychosocial progress note entered by social services on 12/30/24 at 9:15 a.m. indicated resident 5 was seen for session today. Concerns were addressed with nursing staff.
-There was no documentation to support what those concerns were.
4. Interview on 3/12/25 at 10:08 a.m. with administrator A revealed:
*She was made aware of the 12/25/24 reported incident on 12/27/24 via email from DON P.
*DON P told her that she did not suspect abuse.
*She had spoken with resident 5 in passing and she had not expressed any concerns regarding the 12/25/24 incident with CNA R.
*She and DON B had reviewed resident 5's skin assessment and there were no identified concerns.
-There was a skin assessment completed on 12/20/24, prior to the incident, and the next skin assessment was completed on 1/10/25, 16 days after the incident.
-The grievance was documented as resolved on 12/27/24.
*She confirmed that the 12/25/24 grievance written by RN Q was concerning as an allegation of abuse.
*She would have reported abuse to the South Dakota Department of Health (SD DOH) if it was warranted or if she could prove it was abuse.
5. Interview with 3/12/25 at 1:13 p.m. with DON B revealed:
*Any staff member had the ability to complete a SD DOH facility reported incident (FRI) report related to a suspicion of abuse.
*It was her expectation that she be notified of an incident and the charge nurse should complete the SD DOH FRI report.
*She did not feel that a report should have been made to the SD DOH regarding the 12/25/24 reported incident with resident 5 because there were no injuries identified.
*She verified the documents available regarding the 12/25/24 reported incident included the grievance form, the documentation completed by RN Q, the 12/27/24 email sent by DON P to administrator A and DON B, and documentation that CNA R 's travel employment agency had been notified of the grievance and her contract was terminated early on 1/6/25.
-She confirmed she was unable to locate further documentation to support the resident's grievance had been thoroughly investigated to ensure abuse had not occurred.
Review of the provider's undated Reporting Abuse to Facility Management policy revealed:
*Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
*Reports of any suspected abuse or incidents of abuse must immediately be reported to the Social Services Director, Administrator, and the Director of Nursing. In the absence of those listed above, such reports may be made to the Nurse Supervisor on duty.
*The Administrator, Social Services Director and Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator, Social Service Director and/or Director of Nursing must be called and informed of such incident.
*When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy.
*A completed copy of documentation forms and witness statements, if any, must be provided to the Administrator within 24 hours of the occurrence of an incident of suspected abuse. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator within 5 working days of the occurrence of such incident.
*Upon receiving information concerning a report of abuse, the Director of Nursing will request that Social Services monitor and document the resident's reactions to statements regarding the incident and their involvement in the investigation.
*Unless the resident requests otherwise, the Social Service Director will give the Administrator and the Director of Nursing a written report of their findings.
Review of the provider's undated Abuse Investigation policy revealed the following:
*All reports of resident abuse, neglect, injury of unknown source and misappropriation of resident property shall be promptly and thoroughly investigated by facility management.
*The individual conducting the investigation will, as [at] a minimum:
-a. Review the completed documentation form
-b. Review the resident's medical record to determine events leading up to the incident
-c. Interview the person(s) reporting the incident
-d. Interview any witnesses to the incident
-e. Interview the resident (as medically appropriate)
-f. Interview the attending physician as needed to determine the resident's current level of cognitive function and medical condition
-g. Interview staff members who have contact with the resident during the period of the alleged incident
-h. Interview the resident's roommate, family members, and visitors as needed
-i. Interview other residents to whom the accused employee(s) provides care or services for
-j. Review all events leading up to the alleged incident.
*Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports.
*The results of the investigation will be recorded on approved documentation forms.
*The Administrator or his/her appointed member of management will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the Local Policy Department, the Ombudsman and others as may be required by state or local laws, within (5) working days of the reported incident.
Review of the provider's undated Mandatory Reporting policy revealed the following:
*Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
*Willful means the individual intended the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish.
*Do an investigation, review the findings, and revise the care plan as necessary.
*Do an investigation and report per the appropriate timeline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure documentation related to a grad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure documentation related to a gradual dose reduction (GDR) had occurred to support the rationale for not completing a GDR for one of one sampled resident (5) who received psychotropic medications (any medication that affects brain activities associated with mental processes and behaviors). Findings include:
1. Observation and interview on 3/9/25 at 3:42 p.m. of resident 5 in her room while she was in bed revealed she had slow slurred speech.
2. Review of resident 5's electronic medical record (EMR) revealed:
*She was admitted on [DATE].
*Her 12/26/24 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact.
*Her diagnoses included schizoaffective disorder (a mental health condition that includes symptoms of both schizophrenia and mood disorder), depression, and anxiety.
*She had a physician order to receive mental health services.
*She had multiple psychotropic medications ordered for her schizoaffective disorder including:
-Aripiprazole 5 mg (milligrams) daily.
-Bupropion 150 mg twice daily.
-Clozapine 100 mg at bedtime.
-Divalproex delayed release 500 mg twice daily.
*She had been on the same dose of Divalproex since 3/19/24.
*The Consultant Pharmacist Review 2024 and 2025 annual forms did not include divalproex as a psychotropic medication.
*Her Abnormal Involuntary Movement Scale (AIMS) evaluations (a rating scale to measure involuntary movements that can sometimes develop as a side effect of long-term use of antipsychotic medications) was a zero until 12/28/23, when it increased to two and then on 3/19/24 it increased to a four, which indicated an increase in involuntary movements.
*Review of the mental health providers progress notes revealed:
-There was no documentation of notification related to the change in the AIMS score.
-Each visit contained the statement, Previous attempts to GDR resident's psychotropic medications have failed with exacerbation of symptoms including hospitalization, the current medications are appropriate for diagnosis and provided in appropriate amounts. NO GDR is considered or appropriate for this resident.
--There were no changes documented to the divalporex.
--Other psychotropic medications had been dose adjusted or changed to or from a different medication.
*Review of minimum data set (MDS) assessments (a standardized comprehensive assessment of functional, medical, psychosocial, and cognitive status) completed revealed:
*A GDR had not been attempted since 8/18/2020.
*She had not been hospitalized in the past year.
3. Interview on 3/11/25 at 3:26 p.m. with director of nursing (DON) B revealed:
*During a phone conversation on 3/11/25 with consultant pharmacist N, DON B was told that consultant pharmacist N did not complete GDR recommendations for residents that were prescribed psychotropic medications and were being seen by mental health because the mental health provider managed their medications.
*She had not been previously aware that he was not completing GDR recommendations for residents that were on a psychotropic medication and being seen by a mental health provider.
4. Interview on 3/11/25 at 4:37 p.m. with consultant pharmacist N revealed:
*He verified that if a medication that was not classified as a psychotropic and it was being used to affect a person's mental state it would qualify for a GDR review.
*He did not complete GDR reviews or provider recommendations for residents who were prescribed psychotropic medications and receiving mental health services.
*He considered every visit with a mental health practitioner a GDR visit.
*If a resident was on more than one psychotropic medication and one of the medications was changed, he had not been addressing the other medications for GDRs.
*He did not address each psychotropic medication individually when a resident was on more than one.
*He indicated he would have asked for a diagnosis clarification if a medication was being used as a psychotropic medication that was not in a class of medications identified as a psychotropic medication.
*Divalproex (a medication used to treat seizures that is also used as a mood stabilizer) was on resident 5's medication list with a diagnosis of schizoaffective disorder and was not being addressed as a medication that required a GDR, according to the list on his Consultant Pharmacist Review 2024 and 2025 annual forms.
*He stated there may have been a gap in services when a GDR was not presented to the resident's primary care physician or mental health provider.
5. Interview on 3/12/25 at 11:27 a.m. with assistant director of nursing (ADON) G revealed neither the physician nor the mental health provider was notified of the changes in resident 5's AIMS evaluations.
6. Review of the provider's undated Antipsychotic Medication Policy revealed the following:
*Nursing will monitor antipsychotic drug use daily noting any adverse effects such as increased somnolence (excessive sleepiness), functional decline, cardia [cardiac] arrhythmias (abnormal heart rhythm), parkinsonism (characterized by the same motor symptoms as Parkinson's disease), akathisia (movement disorder characterized by a feeling of restlessness and an inability to sit still), tardive dyskinesia (repetitive, involuntary movement disorder), dystonia (involuntary, sustained muscle contractions), anticholinergic effects (side effects caused by medications that block the action of the neurotransmitter acetylcholine), orthostatic hypotension (low blood pressure after standing up from a sitting or lying position) and cerebrovascular evens [events] (conditions that affect the blood vessels in the brain) which can include stroke, TIA [transient ischemic attack] (a mini-stroke), and heart failure. If any of these adverse effects are noted, the charge nurse will chart detailing in progress noted [notes] in [EMR] and notify primary care physician of findings.
*AIMS assessment will be performed every 3-6 months and quarterly psychotropic drug assessment will be performed on a quarterly basis with the MDS assessment schedule and any changes will be reported to the physician.
*Efforts to reduce dosage or to discontinue use of antipsychotics will be ongoing, as appropriate, for the clinical situation. Use will be reviewed at care conferences and recommendations for gradual dose reduction (GDR) will be given to physician, unless clinically contraindicated, to assess effectiveness and/or need for continues [continued] use of antipsychotic. Pharmacy consultant will review [antipsychotic] use and offer recommendations as indicated.
*Definition of Clinically Contraindicated for Antipsychotics:
-The physician has documented the clinical rationale for why an additional attempted dose reduction would likely impair the resident's function or increase distressed behavior.
-For [a] resident with a psychiatric disorder other than dementia:
--a. If the continues [continued] use in [is] in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any additional attempted dose reduction would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder.
--b. If the resident's symptoms returned or worsened after the most recent GDR attempt and the physician has documented the clinical rationale for why any additional attempted dose reduction would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on record review and interview, the provider failed to ensure the proper Medicare Notices were completed accurately for:
*Two of two sampled residents (10 and 33) who had remained in the facilit...
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Based on record review and interview, the provider failed to ensure the proper Medicare Notices were completed accurately for:
*Two of two sampled residents (10 and 33) who had remained in the facility following their discharge from Medicare part A skilled services.
*One of one sampled resident (41) who had discharged to home following their discharge from Medicare part A skilled services.
Findings include:
1. Review of resident 10's electronic medical record (EMR) revealed:
*She had a 3/4/25 Brief Interview for Mental Status (BIMS) assessment score of 14, which indicated she was cognitively intact.
*Her last covered day of Medicare Part A skilled services was 10/30/24.
*The section of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form Beginning on with a blank for the date that her Medicare coverage ended was missing and appeared to have been whited out.
*The signature box contained a handwritten note, Phone: [name of family member]/[signature of director of nursing (DON) P].
-There was no documentation of the time of that notification.
-There was no indication that the person phoned was a representative for the resident.
*The date box had a typewritten date of 10/28/24.
2. Review of resident 33's EMR revealed:
*She had a 3/4/25 BIMS assessment score of 15, which indicated she was cognitively intact.
*Her last covered day of Medicare Part A skilled services was 12/24/24.
*The section of the SNF ABN form Beginning on with a blank for the date that stated when her Medicare coverage ended was missing and appeared to have been whited out.
*No box was checked in the Options section to have indicated whether the resident did or did not want to receive care.
*The signature box contained a handwritten note, Telephone: [name of family member]/[signature of DON P].
-There was no documentation of the time of that notification.
-There was no indication that the person phoned was a representative for the resident.
*The date box had a typewritten date of 12/22/24.
3. Review of resident 41's EMR revealed:
*Her last covered day of Medicare Part A skilled services was 12/23/24.
*The section of the SNF ABN form Beginning on with a blank for the date that stated when her Medicare coverage ended was missing and appeared to have been whited out.
*The date box had a typewritten date of 12/20/24.
4. Interview on 3/11/25 at 10:35 a.m. with administrator A regarding the SNF ABN Forms revealed:
*She agreed that the section of the form that included the date Medicare coverage ended was missing from residents 10, 33, and 41's forms and appeared to have been whited out.
*She was unsure why the SNF ABN forms for residents 10 and 33, who were cognitively intact, had been telephone signed by a family member and not the resident.
*She stated that the previous DON P had been responsible for the SNF ABN forms at the time they were provided to residents 10, 33, and 41.
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, interview, record review, and policy review, the provider failed to ensure two of two sampled resident (9 ...
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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 two of two sampled resident (9 and 21) privacy had been maintained related to audio or video monitoring devices. The provider had not followed their policy for video monitoring related to:
*Ensuring a cognitively intact resident had consented and been aware of the monitoring device in his room.
*Staff training and awareness with the devices including which residents had them, when to turn off or block the device to ensure the residents' privacy, the process for consents by the residents and staff, and ensuring a sign was posted to notify others of the video monitoring device.
Findings include:
1. Observation on 3/9/25 at 2:36 p.m. of resident 9's room revealed there was a white ball-shaped device on a stand on the dresser with a camera lens that faced resident 9's bed.
Observation on 3/10/25 at 1:47 p.m. of resident 9's room revealed:
*The above observed device was no longer present.
*There was no signage present at or near the entrance of his room that indicated the use of a video or auditory monitoring device.
Review of resident 9's electronic medical record (EMR) revealed:
*He was admitted on [DATE].
*He had a 1/7/25 Brief Interview for Mental Status (BIMS) assessment score of 14, which indicated he was cognitively intact.
*His diagnoses include anxiety disorder, major depressive disorder, severe with psychotic symptoms, repeated falls, dementia with other behavioral disturbances, and neurocognitive disorder with Lewy Bodies (a brain disease that affects movement, thinking, mood, and memory).
*A 1/29/25 video monitoring consent form that indicated resident 9's son had given verbal consent to director of nursing (DON) B.
-There was no documentation of resident 9 being informed of or signing a consent for the use of the video monitoring device.
*A 2/13/25 physician's order for video monitoring for resident 9's safety.
*The intervention of video monitoring was added to in his care plan on 1/31/25.
-The care plan did not indicate when staff should have shut off or blocked the video monitoring device to ensure resident 9's privacy.
Observation and interview on 3/10/25 at 1:56 p.m. with assistant director of nursing (DON) G in resident 9's room related to the video monitoring device revealed:
*The device that was used for video monitoring was currently not in use because it had not been helpful.
*It was put in place because resident 9 would throw himself on the floor.
*The device was a baby monitoring screen that was to be watched at the nurse's station.
*There was no sign placed at or near the entrance of his room that indicated video monitoring capability or use.
*Assistant DON G then removed the video monitoring device observed above from the top drawer of the resident's dresser that was manufacturer labeled GoodBaby.
Interview on 3/11/25 at 2:29 p.m. with resident 9 revealed:
*He was not aware that there had been a video monitoring device in his room.
*When shown the video monitoring device he indicated he did not know what that device was and asked if it was the camera.
Interview on 3/11/25 at 2:40 p.m. with certified nursing assistant (CNA)/certified medication aide (CMA) J regarding video monitoring in resident 9's room revealed:
*She was aware there was a video monitoring device in the room.
*She was not instructed to turn off or move the video monitor while providing the residents' care.
2. During the entrance conference on 3/10/25 at 8:39 a.m. with administrator A and DON B, administrator A indicated there was an [NAME] type device in resident 21's room.
Observation on 3/9/25 at 3:48 p.m. of resident 21 in her room revealed the following:
*She was seated in her recliner, her feet were elevated, she was covered with a blanket, and her eyes were closed.
-An [NAME] Show (an electronic device that has a drop in feature capable of audio and video recording) was on the bookshelf next to her recliner that was facing her.
*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.
Observation on 3/10/25 at 8:06 a.m. of resident 21 in her room revealed:
*She was lying on her bed, her eyes were closed, and an [NAME] Show device was on the bookshelf at the same height as her bed.
-The device was facing her bed.
*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.
Observation on 3/11/25 at 7:32 a.m. of resident 21 revealed:
*She was in her bed, the [NAME] Show device was on the second shelf of the bookstand with a pink sticky note on the front that showed where the volume buttons were, and a piece of black tape had been placed over the camera shutter.
-The device was turned and facing the wall.
*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 21's EMR revealed:
*Her admission date was 5/3/23.
*Her 1/14/25 Brief Interview of Mental Status assessment score was a 6, indicating she was cognitively impaired.
*Her diagnoses included: dementia, major depressive disorder, abnormal involuntary movements, psychotic disturbance, anxiety, and mood disorder.
*An 8/9/23 physician's order to Make sure [NAME] Show privacy shutter is closed when family is not present. every shift Pull device out of room and put [it] in [the] med room if the shutter is open. Notify DON [director of nursing] if you need to pull it.
*Her 3/10/25 care plan had a 5/9/23 focus area of Due to the possibility of COVID-19, I have the potential for a psychosocial well-being problem and am at risk for social isolation due to limited visitation possibilities during times of high-transmission rates.
-An 8/3/23 intervention for that focus area indicated resident 21 will be allowed to have her [NAME] Show to be in contact with her family via video call. Family will sign a consent and follow policy for use.
Interview and observation on 3/11/25 at 7:36 a.m. with CNA O in resident 21's room revealed she:
*Was not aware of any residents having an [NAME] Show or any other recording device in their rooms.
*Stated there were night lights in resident rooms that look like an [NAME] device, and when you touch it the night light turns on.
*Observed resident 21's [NAME] Show and stated she was unsure if it was a device that had audio or video monitoring capabilities.
Interview on 3/11/25 at 7:42 a.m. with resident care coordinator/Minimum Data Set (MDS) Coordinator H regarding video and audio monitoring devices revealed:
*She was aware of an [NAME] Show device in resident 21's room.
-Staff were to turn the camera away from resident 21 when they provided care for her to ensure her privacy was maintained.
-Resident 21's family had wanted the device in her room.
-She was unsure of how long it had been in her room.
*She was unsure if resident 21's family used the device's video feature with other family members.
*She had not removed the camera from resident 21's room.
3. Interview on 3/11/25 at 8:32 a.m. with DON B, administrator A, and assistant DON G regarding audio/video monitoring devices in resident's rooms revealed:
*DON B stated the [NAME] Show in resident 21's room was not used for video purposes.
-She thought it was used for the family to look at pictures when they visited resident 21, and was aware resident 21's daughter used the device for audio calls to other family members when she visited.
-Administrator A and DON B were not aware that the [NAME] Show device had a drop-in feature (a feature that allows instant video or audio conversations by outside contacts.)
*DON B indicated resident 9 and his son were aware of the video monitoring device in his room.
-DON B stated the device's video feature was to be turned off by staff when they provided care for the resident for privacy, and the device was in his room to monitor his behaviors and to be able to visualize if he throws himself on the floor.
*DON B stated staff were educated verbally to turn the camera away when they provided personal care to resident 9.
-That education was not documented.
*Assistant DON G stated that everyone knows to turn the device away from the resident while they provided care for that resident to maintain his privacy.
4. Interview and policy review on 3/11/25 at 4:45 p.m. with Administrator A, DON B, and assistant DON G, regarding audio/video device consents and the audio/video monitoring policy revealed the following:
*The policy included a consent was to be signed by staff members.
-Administrator A indicated none of the staff had signed the consent form.
*Administrator A thought the audio/video recording devices would be hooked up to the provider's guest Wi-Fi that was available to all residents and families with codes that were posted at the entrance to the facility.
-Administrator A stated the provider had not needed to provide written approval to the resident or their representative for the use of video recording devices to be used on the provider's guest Wi-Fi.
5. Review of the provider's undated Video Monitoring policy revealed the following:
*Nursing staff must also complete and sign the consent form before a video monitoring device may be installed in the resident's room. The nursing staff member may refuse or withdraw consent to video monitoring.
*Video monitoring restrictions:
-Audio recording is prohibited.
-A resident may not use a facility's local area network to connect the video monitoring device to the internet without the facility's written consent.
-The facility may impose conditions on the installation of any wire, cable, or other technologies that may be necessary to connect the device to the internet.
*1. Resident Consent
-The description of the video monitoring device I wish to install:
--Brand Name:
--Model Number:
--Installation and operating requirements:
*3. Restrictions (Please Indicate)
-No restrictions
-The video monitoring device must be pointed away from ______________ [blank line]
-No video recording
-No broadcasting video recordings
-Video monitoring device must be turned off or blocked during an examination or procedure by a health care provider.
-Video monitoring device must be turned off or blocked while dressing, bathing, or personal care planner, intimate partner, ombudsman, spiritual advisor, or another visitor.
-Other restrictions:
*5. Staff Consent to Video Monitoring in [name] (resident) Room.
-Signature
-Consent
-Do Not Consent
*The last page of the policy indicated a sign was to be posted that included THIS ROOM CONTAINS A VIDEO MONITORING DEVICE.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation and interview on 3/10/25 at 8:51 a.m. of resident 142 revealed she:
*Was seated in a wheelchair by the bathing ro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation and interview on 3/10/25 at 8:51 a.m. of resident 142 revealed she:
*Was seated in a wheelchair by the bathing room.
*Stated she was recently admitted for occupational therapy and physical therapy.
*Planned to return to her home within the next 30 days.
Review of resident 142's EMR revealed:
*She was admitted on [DATE].
*Her 3/4/25 BIMS assessment score was a 14, which indicated her cognition was intact.
*Her diagnoses included: muscle weakness, Erythema Intertrigo (redness, inflammation, and irritation in the skin folds), lumbar radiculopathy (compressed or irritated nerves in the back that may cause pain and other symptoms), and retention of urine.
*Her 3/4/25 baseline care plan included focus areas of:
-She did not have a POA (financial and care).
-She had the potential of a psychosocial well-being problem related to her major life adjustment of having admitted to the facility and losing her independence.
-To ensure on or before admission, and throughout stay, I am reviewed for appropriateness of placement.
3. Interview on 3/11/25 at 2:32 p.m. with social service director E regarding resident's baseline care plans revealed she was not aware if anyone:
*Did or should have reviewed the baseline care plans with residents and/or their representative within 48 hours of the residents' admission.
*Provided the baseline care plan to the resident and/or their representative within 48 hours of the residents' admission.
Interview on 3/11/25 at 3:20 p.m. with director of nursing (DON) B regarding baseline care plans revealed:
*She thought the Interim Care Plan (ICP) assessment demonstrated compliance with the baseline care plan requirements.
*The Minimum Data Set (MDS) nurse had been responsible for completing the baseline care plans and had exceeded the required 48-hour time frame.
-The ICP assessment was changed to one of the charge nurse's duties while completing the admission process for new residents.
Interview on 3/11/25 3:38 p.m. with DON B regarding baseline care plans revealed:
*There was no documentation the resident and/or their representative reviewed and was given the baseline care plans.
-She was not aware that a baseline care plan should have been reviewed and given to the resident and/or their representative within 48 hours of the resident's admission.
Interview on 03/11/25 at 4:50 p.m. with administrator A revealed she was not aware baseline care plans should have been reviewed with and given to the resident and/or their representative within 48 hours of the residents' admission.
4. Review of the provider's December 2024 Care Plan Policy and Procedure revealed:
*Upon admission, resident will be assessed by the Charge Nurse and a baseline care plan will be developed with information gathered from the resident and the resident's family.
*The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status.
*The policy had not addressed the requirements for the baseline care plan:
-To be developed within 48 hours of a resident's admission.
-To be provided to the resident and their representative.
Based on observation, record review, interview, and policy review, the provider failed to review with the resident or their representative, and provide a written summary of the baseline care plan for two of two sampled residents (25 and 142) within 48 hours of their admission.
Findings include:
1. Observation of resident 25 on 3/9/25 at 5:24 p.m. in the main dining room revealed:
*He had glasses on and was seated in his wheelchair at a table.
*He turned from the table and self-propelled his wheelchair to turn to another table and around the dining room.
-Licensed practical nurse (LPN) I assisted the resident returning to his table.
Interview with LPN I at that time revealed the resident was blind in one eye, had low vision in his other eye, and he was hard of hearing.
Review of resident 25's electronic medical record (EMR) revealed:
*He was admitted on [DATE].
*His admission diagnoses included: muscle weakness, history of falling, abnormalities of gait and mobility, low vision in both eyes, anemia (low iron), and chronic congestive heart failure.
*His 8/30/24 4:00 p.m. initiated interim care plan assessment was finalized/locked on 9/3/24 and indicated his 8/30/24 baseline care plan had included focus areas of:
-Activities of daily living (ADL) assistance with transferring, ambulating, locomotion, dressing, personal hygiene, eating, toilet use, and bathing.
-Visual impairment related to his severely impaired visual function.
-Communication problems related to his hearing impairment.
-Mobility assistance related to his history of falls, visual impairment, and gait/balance problems.
*His 9/3/24 Brief Interview of Mental Status (BIMS) assessment score was 8, which indicated his cognition was moderately impaired.
*There was no documentation that indicated the interim/baseline care plan had been reviewed or given to the resident or his representative.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to follow professional standards of pract...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to follow professional standards of practice related to:
*Physician notification of and implementation of appropriate interventions for one of one sampled resident's (36) significant weight loss as directed in their policy.
*Identification and implementation of interventions for one of one sampled resident (5) with low blood sugars.
*Holding the administration of insulin for one of one sampled resident (5) with low blood sugars without a physician's order.
Findings include:
1.Observation on 3/9/25 at 3:39 p.m. of resident 36 in the hallway revealed she had significant swelling to her ankles.
Review of resident 36's electronic medical record (EMR) revealed:
*She was admitted on [DATE].
*Her 3/5/25 Brief Interview of Mental Status (BIMS) assessment score was 1, which indicated she had severe cognitive impairment.
*Her diagnoses included disorder of electrolyte and fluid balance, heart failure, dehydration, and dementia.
*A 2/10/25 physician's order for Ace wraps (elastic bandages) daily PRN (as needed) for edema (fluid retention and swelling).
-There were no directions that addressed the location of ace wrap application or how long the ace wraps should be left on.
*A 2/11/25 physician's order for torsemide (a medication for fluid retention and swelling) 20 mg (milligrams) daily.
*She did not have a physician's order for nutritional supplements.
*It was documented from 2/17/25 through 3/4/25 resident 36 was offered a snack five times and accepted snacks three times.
Review of resident 36's documented weights revealed:
*On 2/3/25 she weighed 119 pounds.
*On 2/4/25, 2/7/25, and 2/11/25 she weighed 120 pounds.
*On 2/18/25 she weighed 122 pounds.
*On 2/21/25, 2/25/25, 2/28/25, 3/4/25, and 3/7/25, she weighed 110 pounds.
-On the 2/25/25 manager meeting notes, it was indicated resident 36 needed a reweigh related to weight loss.
--The reweigh confirmed resident 36's weight loss.
Observation on 3/10/25 at 1:51 p.m. of resident 36 in the hallway revealed ace wraps were not on her lower legs. There was no swelling to her lower legs or ankles noted at that time.
Review of resident 36's treatment administration record (TAR) for February and March 2025 indicated no documented use of ace wraps for swelling.
Review of resident 36's progress notes revealed:
*On 2/3/25 at 1:04 p.m. a dietary note indicated, [Resident 36] scored a 4 on her MNA [mini nutritional assessment]. (Malnourished) She was recently hospitalized for septic shock and was placed on a feeding tube. The tube has been removed, and she is eating well, over 76% and she has had a swallowing eval [evaluation]. Her current diet is Mechanical Soft with moist foods. She is tolerating [it] well. She did lose 23# [pounds] while in the hospital. [Resident 36] is sitting with the restorative aide. They will encourage and help [resident 36] eat.
*There were no notes addressing resident 36's weight loss of 12 pounds from 2/18/25 to 2/21/25 that was indicated in her weight records.
*On 3/3/25 at 10:53 a.m. a skilled note indicated, She has 3+ [deep pitting when an area is pressed on] edema [swelling] in her left lower leg and 2+ [moderate pitting] edema in the right.
*On 3/6/25 at 2:23 p.m. a skilled note indicated, She has 2+ edema to her left lower leg and 1+ [mild pitting] in the R [right] lower leg.
*On 3/11/25 at 12:43 p.m. a nutrition/dietary note indicated, [Resident 36] has had a significant weight loss which could be from fluid [changes]. She is eating meals over 76% and is not having trouble chewing or swallowing at this time. She is being monitored, and RD [registered dietician] is aware of these issues.
*On 3/11/25 at 6:11 p.m. a late entry nutrition/dietary note was entered by consultant dietician M that indicated, from discussion on [resident 36] during [a] site visit in February. She is a 81 y.o. [year old] Female with a BMI [body mass index] of 19.5- normal range. Wt. [weight] loss of -10lbs [pounds] over 30 days at 8.5%-moderate weight loss. Weight loss could be due to electrolyte imbalance, fluid imbalances and retention. Edema +3 previously, has reduced since then. New medications reported for fluid and anxiety. Zoloft may interact with diabetes medications causing hypoglycemia reported. Meal consumption has been over 75% and eating well has been reported. Continue goal of at least 75% completion at meals and monitoring weight. Calorie needs: 1,250-1,500 kcal [kilocalories]/day Protein needs: 50-60 grams/day Fluid needs: at least 1,500+ ml [milliliters]/day.
Review of resident 36's 3/10/25 care plan revealed:
*There was a focus area for at risk for possible nutritional problem and risk for dehydration. Weight loss noted while in acute care prior to admit.
-Interventions for this focus area included Encourage intake of food and fluids. Provide and serve diet as ordered. SLP [Speech Language Pathologist] or Dietician Consult [consultation] as needed.
*There were no further interventions related to weight loss on her care plan.
Interview on 3/12/25 at 1:13 p.m. with director of nursing (DON) B revealed:
*If nursing staff put on a resident's Ace wraps it should have been documented on that resident's TAR.
*She confirmed resident 36's Ace wraps had not been documented that they were put on the resident since the physician's order was received on 2/10/25.
*Dietary manager C was to monitor resident weights.
*Dietary manager C was to notify DON B if a resident had a change in weight.
*Consultant dietician M would work with DON B and dietary manager C to address residents with weight loss or significant weight fluctuations.
*DON B would expect the resident's physician to be notified of a resident's confirmed weight gain or loss.
*DON B explained she may monitor a resident's weight, reweigh the resident, and assess for other symptoms.
-She indicated she may not have notified the provider if there were no other symptoms identified with the resident's weight gain or loss.
*DON B verified resident 36's provider had not been notified of the significant weight loss.
Review of the provider's 1/28/25 Maintaining Nutrition Status policy revealed:
*Significant weight changes are 5% in 30 days, 7.5% in 90 days or 10% in 180 days.
*Significant weight losses will be reviewed by [the] Care Team and reported to [the] Residents [resident's] Physician/RD.
*Care team will evaluate possible additional interventions to promote good nutritional status to residents when normal interventions (Supplements, Restorative dining program, Diet change) have proven unsuccessful in stop [stopping] unplanned weight loss when [the] loss is not unavoidable.
Review of the provider's undated Notification of Changes policy revealed:
*The purpose of this policy is to ensure that [the provider] promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.
*Circumstances requiring notification include:
-Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.
-Circumstances that require a need to alter treatment.
2. Interview on 3/9/25 at 3:42 p.m. with resident 5 in her room revealed she sometimes had low blood sugars.
Review of resident 5's EMR revealed:
*She was admitted on [DATE].
*Her 12/16/24 BIMS assessment score was 15, which indicated she was cognitively intact.
*She had a diagnosis of diabetes.
*She had a 7/10/18 physician's order to check her blood sugars three times daily.
*She had an order for, NovoLOG Solution 100 units/ML [milliliter] (Insulin Aspart) [fast-acting insulin] Inject 10 units subcutaneously [the fatty tissue layer under the skin] three times a day related to TYPE 2 DIABETES MELLITUS.
*She was to receive Soliqua Subcutaneous Solution Pen-Injector 100-33 UNT[unit]-MCG[microgram]/ML[milliliter] (Insulin Glargine-Lixisenatide) [long-acting insulin] Inject 40 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEPHROPATHY.
*There were no parameters provided on the physician's order to indicate if and when the insulins should have been held.
Review of resident 5's blood sugars and progress notes from December 2024 through February 2025 revealed:
*A progress note on 12/7/24 indicated resident 5's lunch novolog was held due to a blood sugar of 74 (below 70 is considered low for most individuals).
*On 12/10/24 at 11:43 a.m. resident 5's blood sugar was 50.
-The next blood sugar check was 85 at 4:24 p.m. on 12/10/24.
*On 1/27/25 at 5:35 p.m. resident 5's blood sugar was documented as 67.
-The next blood sugar documented was 128 at 7:10 a.m. on 1/28/25.
*Resident 5's blood sugar was documented as 213 at 11:40 a.m. on 1/29/25.
-A progress note on 1/29/25 at 12:30 p.m. indicated, Resident BS [blood sugar] was 213 prior to lunch. While sitting at the dining room table she was drooling, lethargic and not easy to arouse. I took Her BS and it [had] dropped to 51. DON [director of nursing] gave glucose gel to her. Will recheck BS.
-A progress note on 1/29/25 at 12:50 indicated, Resident is now awake and feeding herself. She is answering questions and responding.
-The next blood sugar documented was 103 at 1:24 p.m. on 1/29/25.
*A progress note on 1/31/25 at 4:35 p.m. indicated resident 5's NovoLog was held due to a blood sugar of 89.
*A progress note on 2/1/25 at 12:05 p.m. indicated resident 5's NovoLog was held due to a blood sugar of 95.
*A progress note on 2/10/25 at 11:53 a.m. indicated resident 5's NovoLog was held due to a blood sugar of 85.
*A progress note on 2/13/25 at 8:22 a.m. indicated resident 5's NovoLog and Soliqua were held due to a blood sugar of 89.
*A progress note on 2/22/25 at 9:06 a.m. indicated resident 5's NovoLog and Soliqua insulins were held due to a blood sugar of 89.
*A progress note on 2/23/25 at 4:56 p.m. indicated resident 5's NovoLog was held due to a blood sugar of 96.
*On 2/24/25 at 10:39 a.m. resident 5 had a blood sugar result of 63.
-There was no progress note that indicated she was symptomatic or if there were actions taken to address the low blood sugar.
-The next documented blood sugar check on 2/24/25 at 1:11 p.m. was 150.
*A progress notes on 2/26/25 at 4:58 p.m. indicated resident 5's NovoLog insulin was held for a blood sugar of 76.
Review of the provider's documentation of physician notification related to resident 5's blood sugars and insulins for 12/1/24 through 3/11/25 revealed:
*There were physician progress notes on 12/31/24 and 2/18/25 that indicated the physician had been notified of high blood sugars.
*There was no documentation of physician notification related to the resident's insulins being held or the resident's low blood sugars related to the occurrences identified in the resident's progress notes.
Interview on 3/11/25 at 2:32 p.m. with resident care coordinator/Minimum Data Set (MDS) coordinator H regarding blood sugar parameters revealed:
*Per their providers' standing order a low blood sugar was one less than 70 and a high blood sugar was over 400.
*If she identified a resident with a low blood sugar she would hold the insulin, give the resident a glass of juice and recheck the blood sugar in 15 minutes.
*She would document the blood sugar recheck in the EMR under the vital signs tab.
Interview on 3/12/25 at 1:13 p.m. with director of nursing (DON) B regarding low blood sugars revealed:
*Her expectation was for staff to follow the provider's policy.
*She indicated the treatment for a resident with a low blood sugar would be to give glucagon or something according to the physician's standing orders.
*She would expect a blood sugar recheck after treatment for a low blood sugar.
*She expected interventions and follow up regarding low blood sugars to be documented in the resident's EMR.
Review of the provider's undated Physician Standing Orders policy revealed the following:
*Diabetic Management:
-Notify provider if two BG [blood glucose] results are < [less than] 70 or > [greater than] 400 in a 24-hour period and/or change in condition; if no condition change, notify provider on the next business day.
*Hypoglycemia (BG <70)
*If resident is symptomatic, conscious, and able to swallow or has a feeding tube:
-Administer 6 ox [ounces] fruit juice, milk, regular pop, or other high carbohydrate beverage (eg. Ensure, Boost) orally or via feeding tube.
-Repeat BG after 15 minutes; if <70 repeat above intervention.
-If after 2 attempts to treat and BG still <70, notify provider.
*Once resident is stable, recheck BG after 60 minutes.
*Communicate occurrence of any hypoglycemic event to provider the next business day.
Review of the provider's undated Medication Management policy revealed, Medications are administered in accordance with written orders of the attending physician or physician extender.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · 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 assess two of two (24 and 36) sampled ...
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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 assess two of two (24 and 36) sampled residents for their need for trauma-informed care.
1. Observation and interview on 3/9/25 at 3:10 p.m. with resident 24 revealed:
*Her room had piles of clothing, books, and papers.
*She believed someone had taken some of her belongings.
*She believed her daughters had been molested by her husband.
Review of resident 24's electronic medical record (EMR) revealed:
*She was admitted on [DATE].
*Her 1/27/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact.
*Her diagnoses included anxiety and major depressive disorder.
-A copy of resident 24's trauma-informed care assessment was requested from the provider on 3/11/25 at 4:10 p.m. but was not provided for review by the end of the survey.
Review of resident 24's 3/10/25 care plan revealed:
*She had a focus area of, behavior problem r/t [related to] Depression and Anxiety Disorders. History and current events of the following: refusal of care, verbal/physical behaviors that are inappropriate and directed towards staff, hoarding, self-isolation, and allegations of abuse and neglect. Along with manipulative behaviors such as misinformation and alterations in the truth.
-One of the interventions was Provide education to staff yearly and as needed regarding behaviors and trauma-informed care.
*She had a focus area of has a psychosocial well-being problem r/t Anxiety, several Disease Processes, and ineffective coping secondary to a past history of trauma and medical history of bipolar disorder.
-Interventions for this were Identify items that may trigger s/sx [signs and symptoms] of trauma-related responses or lessen the effects of trauma and provide comfort.
-There was no documentation to support resident 24 had been assessed to determine if she had trauma or what her triggers would have been.
2. Observation on 3/9/25 at 3:39 p.m. of resident 36 revealed:
*She hollered for help repeatedly.
*She had repetitive and random indistinguishable vocalizations.
*She wheeled her wheelchair in and out of her room repeatedly.
Review of resident 36's EMR revealed:
*She was admitted on [DATE].
*Her 3/5/25 BIMS assessment score was 1, which indicated severe cognitive impairment.
*Her diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
*There was no trauma-informed care assessment in resident 36's EMR.
Review of resident 36's 3/9/24 care plan revealed it did not contain a focus area or interventions for her behaviors and vocalizations.
Interview on 3/12/25 at 11:08 a.m. with administrator A regarding trauma-informed care revealed:
*The provider did not complete an assessment for any residents on admit or re-admission.
*The provider did not assess or reassess any residents for trauma-informed care.
Review of the provider's 4/20/19 Trauma Informed Care Plan and Procedure revealed:
*Trauma-Informed Care understands and considers the pervasive nature of trauma and promotes environments of healing and recovery rather than practices and services that may inadvertently re-traumatize.
*Trauma Informed care will be addressed in the care plan of noted residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the provider failed to ensure residents who used bed rails/as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the provider failed to ensure residents who used bed rails/assist bars had:
*A signed consent for their use for two of twelve sampled residents (23 and 25).
*The medical symptoms for use documented on the Side Rail Assessments for five of twelve sampled residents (6, 9,13, 21, and 36).
*Received education on the risks of use versus benefits of use of side rails/assist bars for one of twelve sampled residents (9).
*Other attempted interventions documented on the Side Rail Assessment for one of twelve sampled residents (23).
Findings include:
1. Review of resident 23's 2/23/25 Side Rail Assessment revealed the area that was to indicate if a consent form had been signed was left blank.
2. Review of resident 25's 1/25/25 Side Rail Assessment revealed the area that was to indicate if a consent form had been signed was left blank.
3. Review of resident 6's 1/12/25 Side Rail Assessment revealed the area that was to have her medical condition/symptoms that made side rails necessary was left blank.
4. Observation on 3/9/25 at 2:36 p.m. of resident 9 revealed he had two quarter-length side rails in the up position at the head of his bed.
Review of resident 9's 4/28/20 Side Rail Assessment revealed the area that was to have his medical condition/symptoms that made side rails necessary was left blank.
5. Review of resident 13's 3/4/25 Side Rail Assessment revealed the area that was to have her medical condition/symptoms that made side rails necessary was left blank.
6. Observation on 3/10/25 at 8:06 a.m. of resident 21 revealed:
*She was lying in her bed with her eyes closed.
*Her bed had side rails on both sides of her bed in the up position.
Review of resident 21's electronic medical record revealed:
*She was admitted on [DATE].
*Her 1/14/25 Brief Interview of Mental Status assessment score was a 6, which indicated she had severe cognitive impairment.
*Her 3/10/25 care plan indicated:
-She was cognitively impaired.
*She was to demonstrate the appropriate use of assist bars to maintain her ability to participate in bed mobility.
Review of resident 21's 1/14/25 Side Rail Assessment revealed the area that was to have her medical condition/symptoms that made side rails necessary had documented POA requested Assist rails on bed.
7. Observation on 3/9/25 at 2:31 p.m. of resident 36 revealed she had two quarter-length side rails in the up position at the head of her bed.
Review of resident 36's 1/29/25 Side Rail Assessment revealed the area that was to indicate medical condition/symptoms that made side rails necessary had POAs request side rails documented on it.
8. Further review of resident 9's 4/28/20 Side Rail Assessment revealed the are labeled Potential risks reviewed with resident and/or significant others was left blank.
9. Further review of resident 23's 2/23/25 Side Rail Assessment revealed:
*The area to record other interventions included POA signed consent for assist bars and requests that She has them.
10. Interview on 3/11/25 at 7:54 a.m. with resident care coordinator/minimum data set coordinator H regarding resident side rail/assist bar use revealed when a resident was admitted they were to be assessed by the admitting nurse for appropriate use of side rails by completing the Side Rail Assessment.
11. Interview on 3/11/25 at 4:42 p.m. with director of nursing (DON) B, assistant DON G and administrator A regarding side rail/assist bar use revealed:
*DON B indicated consent forms should be signed by the resident or their representative.
*The Side Rail Assessment should be completed in full for each resident.
*Administrator A stated she was not able to speak to this [topic].
12. Interview and record review on 3/11/25 at 5:31 p.m. with Administrator A and DON B regarding the use of side rails revealed DON B stated the process fell apart.
13. Review of the provider's undated Bed Assist Bar Policy & Procedure revealed:
*Policy:
-Use bed assist bars to enhance resident mobility and independence.
-Make sure resident and/or representative aware of risks of bed assist bars.
-Ensure ongoing assessment and maintenance of resident bed assist bar use.
*Procedure:
-1. Prior to installation of bed assist bar, charge nurse or designee must complete Assistive Device Assessment to determine appropriateness of using bed assist bars.
-2. Decision to install bed assist bar shall be made based on the following information assessed in the Assistive Device Assessment:
--a. Determine the reason for the bed assist bar and if it is likely to [for] the resident [to] meet his or her needs.
--b. Evaluation of any bed assist bar alternatives attempted that failed to meet the resident's needs prior to use and installation and alternatives considered but not attempted because they were considered to be inappropriate.
--c. Assess the resident for risks to safety with use of bed assist bar including cognition, mobility, communication, etc.
-Bed rail/assist bar evaluation form will be completed quarterly to assess appropriateness and need for continued use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · 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 medications were labeled prop...
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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 medications were labeled properly for four of four random residents (3, 5, 20, and 32) related to having the pharmacy label remain with the medication and to follow the manufacturers' instructions for use-by dates.
*Ensure proper labeling and storage of medication for one of one resident (29) with a medicated ointment stored unsecured in her room.
Findings include:
1. Observation on 3/10/25 at 2:32 p.m. of the medication storage room with certified medication aide (CMA) Z revealed:
*There were three insulin pens on the top of the treatment cart.
-The pens were labeled for residents 3, 5, and 20.
*All three insulin pens had the pharmacy label attached to the removable cap.
*All three insulin pens were insulin aspart (a fast-acting insulin) and were not labeled with a date to have indicated when the pen was removed from the refrigerator for its first use or when they should have been used by.
2. Interview on 3/10/25 at 2:47 p.m. with assistant director of nursing (ADON) G revealed:
*She confirmed the insulin pens were not dated when opened to ensure they were used by or discarded according to the manufacturer's instructions for use.
*She confirmed there was a possibility the removable caps on the insulin pens could have been switched between resident's insulin pens.
-With the pharmacy labels being on the removable caps of the pens it could not be verified to only be used for the specific resident that pen was dispensed to.
*She was not aware of a resource list for medications with shortened expiration dates (a resource that indicated how long a medication could be used for once it was opened for use if it was different than the original expiration date).
3. Observation on 3/11/25 at 7:26 a.m. of the medication carts revealed:
*A bottle of Latanoprost eye drops for resident 32 was not marked with a date to indicate when the bottle was opened.
*A bottle of Latanoprost eye drops for resident 3 was not marked with a date to indicate when the bottle was opened.
4. Interview on 3/11/25 at 8:00 a.m. with certified nursing assistant/certified medication aide (CNA/CMA) K revealed:
*All medications were supposed to be dated when opened.
*She thought there was a guideline for staff to use for medications that had specific use-by dates, but she was unsure where it was located.
5. Interview on 3/11/25 at 10:36 a.m. with director of nursing (DON) B revealed:
*She was not aware there were medications that had specific use-by dates after opening.
*If insulin pens were not dated there was no way to confirm they were being used prior to the use-by date.
6. Observation and interview on 3/9/25 at 4:08 p.m. with resident 29 revealed:
*There was a container of partially used Vicks Vapor rub ointment on her bedside table in her room.
*The Vicks Vapor rub was not stored in a secure location to prevent other residents or unauthorized staff from accessing the medication.
7. Interview on 3/10/25 at 1:54 p.m. with ADON G revealed:
*Resident 29 did not self-administer medications and should not have had medications stored in her room.
*The Vicks Vapor rub may have been on the table in her room, but the night nurse puts it on her.
8. Observation on 3/11/25 at 2:26 p.m. of resident 29's room revealed:
*The Vicks Vapor rub was in the top drawer of her bedside stand.
*There was no resident name or date on the container that indicated who it was for or when it was opened.
9. Interview on 3/11/25 at 2:39 p.m. with CNA/CMA K and resident care coordinator/Minimum Data Set coordinator H revealed:
*They were not aware resident 29 had Vicks Vapor rub at her bedside.
*Vicks Vapor rub would not normally be left at a resident's bedside.
10. Review of resident 29's electronic medical record (EMR) revealed:
*She was admitted on [DATE].
*Her 3/4/25 Brief Interview of Mental Status (BIMS) assessment score was 6, which indicated severe cognitive impairment.
*She did not have a physician order for Vicks Vapor rub.
11. Interview on 3/12/25 at 1:13 p.m. with DON B revealed:
*Resident 29 should not have had Vicks Vapor rub at bedside.
*It was her expectation that medications were to be dated when opened, appropriately labeled with the resident's name, and stored securely.
Review of the provider's undated Cart Organization and Proper Medication Storage policy revealed:
*When opening any Multi-Dose container/items-they should be dated with the open date immediately.
Review of the provider's undated Medication Storage and Labeling policy revealed the following:
*Labels for multi-use vials must include:
-The date the vial was initially opened or accessed (needle-punctured);
-All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
-Labels for medications designed for multiple administrations (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to assess side rails on 13 of 13 sampled residents' beds...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to assess side rails on 13 of 13 sampled residents' beds (2, 3, 5, 6, 9, 13, 16, 21, 23, 24, 25, 36, and 142) routinely as a part of a safety and preventative maintenance program to ensure those side rails were in good working order and safe from possible resident entrapment or injury. Findings include:
1. Observation on 3/9/25 at 2:31 p.m. of resident 36 revealed she had two quarter-length side rails in the up position at the head of her bed.
2. Observation on 3/9/25 at 2:32 p.m. of resident 24 revealed she had two quarter-length side rails in the up position at the head of her bed.
3. Observation on 3/9/25 at 2:36 p.m. of resident 9 revealed he had two quarter-length side rails in the up position at the head of his bed.
4. Observation on 3/9/25 at 3:42 p.m. of resident 5 revealed she had two quarter-length side rails in the up position at the head of her bed.
5. Observations on 3/9/25 between 3:48 p.m. and 5:30 p.m. and on 3/10/24 between 8:12 a.m. and 11:00 a.m. of sampled resident rooms revealed 2, 3, 5, 6, 9, 13, 16, 21, 23, 24, 25, 36, and 142 had quarter-length side rails on one or both sides of their beds.
6. Interview on 3/11/25 at 3:09 p.m. with maintenance director F regarding safety and preventative maintenance of side rail on residents' beds revealed:
*The physical therapists initiated the use of side rails for residents.
*He was aware of one bed with side rails attached, the bed in room [ROOM NUMBER].
-That resident was not an identified sampled resident.
-That resident had purchased his own bed, and it had a box spring and metal frame, and on 5/2/24 maintenance director F had installed side rails on that bed.
-He monitored only that residents' bed and the side rails attached to it monthly for safety.
*He thought all other residents' beds with side rails in the up position were for the remote of the electronic bed.
*He was not aware the other residents' beds with side rails attached were being assessed by the nursing staff for use as side rails.
-He had not performed safety and preventative maintenance of side rails for any other residents' beds with side rails to ensure they were appropriately secured and in safe working order to prevent injuries.
7. Review of the provider's Transfer Bar/Bed Rail Maintenance Log revealed:
*The form included areas to be documented in as: date, Room # [number] Monitored, Date Repairs Done, Comments, and Initials.
-The first date on the form was on 5/2/24 with Room # Monitored as #11-2, Date Repairs Done 5-2 installed, Comments included will check quarterly and the Initials of [maintenance director F].
Review of the provider's undated Bed Assist Bar Policy & Procedure revealed:
*Policy:
-Ensure ongoing assessment and maintenance of resident bed assist bar use.
*Procedure:
-4. Initial actions to prevent deaths and injuries from entrapment and/or falls from bed assist bars:
--a. Ensure bed dimensions are appropriate for resident.
--b. Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed.
--c. Check with the manufacturer(s) to make sure the bed assist bar, mattress, and bed frame are compatible.
--d. Install bed assist bars using the manufacturer's instructions and specifications to ensure a proper fit.
-5. Inspect and regularly check the mattress and bed assist bar for areas of possible entrapment.
--a. Regardless of mattress width, length, and/or depth, the bed frame, bed assist bar, and mattress should leave no gap wide enough to entrap a resident's head or body.
--b. Check bed assist bars regularly to make sure they are still installed correctly as bars may shift or loosen of loosen over time.
--c. Follow manufacturer equipment alerts and recalls.
--d. Conduct routine preventative maintenance of beds and bed assist bars to ensure they meet current safety standards and are not in need of repair.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on interview, Payroll Based Journal (PBJ) record review, employee timecard review, and policy review, the provider failed to ensure licensed nursing coverage for 24 hours a day for three federal...
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Based on interview, Payroll Based Journal (PBJ) record review, employee timecard review, and policy review, the provider failed to ensure licensed nursing coverage for 24 hours a day for three federal fiscal quarters (Quarter 2, 1/1/24 through 3/31/24; Quarter 3, 4/1/24 through 6/30/24; and Quarter 4, 7/1/24 through 9/30/24).
Findings include:
1. Interview on 3/9/25 at 2:08 p.m. with business office manager C during the entrance conference revealed the provider did not have any licensed nurse staffing waivers.
2. Interview on 3/9/25 at 3:42 p.m. with resident 5 revealed she had been told by staff members on multiple occasions they were short of nurses.
3. Review of the PBJ records submitted to the Center for Medicare and Medicaid Services (CMS) revealed the provider submitted the following for licensed nursing coverage not being covered 24 hours per day for:
*Quarter 2, 2024 for 34 days.
*Quarter 3, 2024 for 11 days.
*Quarter 4, 2024 for 30 days.
4. Review of the provider's employee timecards revealed:
*For Quarter 2, 2024; 24-hour licensed nursing coverage was unable to be verified on 1/1, 1/10, 1/11, 1/12, 1/31, 2/1, 2/2, 2/3, 2/9, 2/20, 2/24, 2/27,3/6, 3/7, 3/12, 3/13, 3/19, 3/20, 3/25, and 3/28.
*For Quarter 3, 2024; 24-hour licensed nursing coverage was unable to be verified on 4/6, 4/13, 4/17, 5/27, and 6/21.
*For Quarter 4, 2024; 24-hour licensed nursing coverage was unable to be verified on 7/13, 8/14, 8/22, 8/23, 8/24, 8/28, 8/29, 9/18, 9/19, 9/20, 9/21, 9/22, 9/25, and 9/27.
5. Interview on 3/10/25 at 6:03 p.m. with business office manager C regarding PBJ data submission revealed:
*She was aware the PBJ reports indicated there were days of not having 24-hours of licensed nursing coverage.
*She did not know how there was missing data because she always got an indicator that 100% of the information was submitted and every report had been accepted.
*She stated she entered the travel staff manually into PBJ and the other staffs' times were pulled in from their timecards.
Review of the provider's undated Nursing Staffing and Posting policy revealed The facility is required to provide licensed nursing staff 24 hours a day (except when waived), along with other nursing personnel, including but not limited to nurse aides.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on Payroll Based Journal (PBJ) reports, interview, staff timecard review, and policy review, the provider failed to ensure:
*A registered nurse (RN) had been scheduled for eight consecutive hour...
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Based on Payroll Based Journal (PBJ) reports, interview, staff timecard review, and policy review, the provider failed to ensure:
*A registered nurse (RN) had been scheduled for eight consecutive hours of coverage for four days in quarter two (January 1 through March 31) of fiscal year 2024.
*There was a full-time director of nursing (DON) for 16 randomly selected weeks between July and December 2024.
1. Interview on 3/9/35 at 2:08 p.m. with business office manager (BOM) C during the entrance conference revealed:
*The provider did not have any nurse staffing waivers.
*She stated the DON worked 36 hours per week.
*The DON was paid hourly.
2. Review of the RN staff timecards for fiscal year 2024 revealed:
*The DON timecard for 2/3/24 was not produced by the provider to verify hours worked.
*RN coverage for eight consecutive hours could not be verified for 1/13/24, 1/14/24, and 2/17/24.
3. Interview on 3/11/25 at 6:00 p.m. with administrator A revealed:
*The Minimum Data Set (MDS) nurse was scheduled from 8:00 a.m. to 5:00 p.m. Monday through Friday during quarter two of fiscal year 2024.
*She was salaried.
*The MDS nurse was a RN and would be considered to cover the requirement for an RN eight consecutive hours per day on the days she worked.
*There was no RN scheduled for eight consecutive hours on 1/13/24, 1/14/24, and 2/17/24.
*DON B had worked on 2/3/24.
4. Interview on 3/12/25 at 7:47 a.m. with administrator A revealed she thought DON B worked between 36 and 40 hours per week.
Review of DON B's timecards revealed during 16 weeks of randomly selected timecards between July and December 2024, DON B averaged 23.125 hours per week.
Review of the provider's undated Nursing Staffing and Posting policy revealed, The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the provider failed to post the required daily nurse staffing information in a prominent location that was readily accessible to residents and visit...
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Based on observation, interview, and record review, the provider failed to post the required daily nurse staffing information in a prominent location that was readily accessible to residents and visitors and to include the actual hours worked of nursing staff.
Findings include:
1. Observation 3/12/25 at 8:00 a.m. of the posted nurse staffing information revealed:
*It was posted on a board near the nurse's station.
*It would not be readable to a resident or visitor in a wheelchair at the height it was posted.
*There were three categories of staff listed on the sheet: RN (registered nurse), LPN (licensed practical nurse), and CNA (certified nursing assistant).
*Under the LPN and CNA category the number of those staff scheduled for the day was listed by shift.
*There were no numbers listed under the RN category.
*There were no documented actual hours worked on the form for the nursing staff.
2. Interview on 3/12/25 at 8:54 a.m. with director of nursing (DON) B about posting the daily staffing revealed:
*CNA/certified medication aide (CMA) K was responsible for developing the schedule.
*CNA/CMA K would then transfer information from the schedule onto a daily assignment sheet.
*The night nurse would use the daily assignment sheet to fill out the daily staffing sheet for the following day and would post it in the morning on the board at the nurse's station.
*DON B was unaware that actual hours worked by each nursing discipline should have been listed on the posted staffing sheet according to the requirements.
*She stated that was an old form and it needed to be updated to include a column for recording actual hours worked of nursing staff.
3. Review of the provider's undated Nursing Staffing and Posting Policy revealed:
*Posting of Staffing
-It is the policy of [provider] to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time.
-The nurse staffing will be posted daily and will contain the following information:
--Facility Name
--The current date
--Facility's current resident census
--The total number and the actual hours worked by the following categories of licensed and
unlicensed nursing staff directly responsible for resident care per shift:
---Registered Nurses
---Licensed Practical Nurses/Licensed Vocational Nurses
---Certified Nurse Aides
-The information posted will be:
--Presented in a clear and readable format.
--In a prominent place readily accessible to residents, staff, and visitors.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
Based on observation, record review, interview and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential the...
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Based on observation, record review, interview and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential theft) to ensure accurate and complete documentation for those medications related to their receipt, counts, administration details including the dates given and the resident names, and destruction process.
Findings include:
1. Observation on 3/10/25 at 2:07 p.m. of the North wing medication cart revealed:
*There was a three-ring binder labeled North Narcotic Binder on top of the medication cart that contained:
-A March 2025 CONTROLLED DRUG COUNT RECORD.
--That form had two columns for nurse initials labeled NURSE ON and NURSE OFF and rows numbered 1 through 31 which indicated days of the month.
--There were no nurse initials for two nurses on 3/1/25 and 3/2/25 and only one nurse on 3/4/25.
-Multiple forms labeled CONTROLLED DRUG RECORD Individual Patient's Narcotic Record.
--Those forms included areas for the resident's name, medication name and strength, directions for administration of the medication, doctor, pharmacy, who the medication was received by, date received, and time received.
*Those forms did not have a pharmacist signature and had only one signature of the individual who received the medication.
2. Observation on 3/10/25 at 2:11 p.m. of the three-ring binder labeled West Narcotic Binder on the west wing medication cart revealed:
*The binder was set up the same as the North Narcotic Binder.
*The [NAME] March 2025 Controlled Drug Count Record had no nurse initials for two nurses on 3/1/25 and 3/2/25 and one nurse on 3/11/25.
*One Individual Patient Record belonged to resident 35, who had discharged from the facility on 3/9/25 and indicated:
-30 tablets of Tramadol (a controlled pain medication) 50 milligrams (mg) received on 7/16/24.
-The Tramadol had been signed out for administration to resident 17 three times, according to staff signatures and the medication count.
-There were no dates documented for the three times the medication was removed for administration.
3. Observation and interview on 3/10/25 at 2:20 p.m. with Certified Medication Aide (CMA) Z revealed:
*She entered the facility with a pharmacy bag that contained residents' prescription medications.
-One of those medications was Morphine (a controlled pain medication) solution (liquid form).
*She obtained a blank Individual Patient's Narcotic Record from the nurse's station and wrote the prescription information on the form.
*She signed that she received the medication, dated it 3/10/25 and identified she received 30.
-She did not identify if the 30 indicated tablets, milliliters, ounces, etc.
*She then placed that Individual Patient's Narcotic Record in the North Narcotic Binder and put the Morphine in a locked compartment in the North medication cart.
*She stated that she had gone to the pharmacy and picked up the medications for the newly admitted resident.
*CMAs or nurses were to complete the Individual Patient's Narcotic Record when the medication was received from the pharmacy and put the form in the appropriate medication cart's binder.
*She did not confirm the quantity of the morphine with another nurse or CMA.
*The controlled drug count record was a different form used by staff to document who counted the controlled medications when they came on and went off their shifts to confirm counts of all controlled medications.
*She indicated that the nurses worked from 6:00 a.m. to 6:00 p.m. and the nurse going off duty would count the controlled medications with the nurse coming on and document the counts on the controlled drug count record form.
*The CMAs worked 7:00 a.m. to 5:00 p.m. so they would count with the nurse on duty when the CMAs arrived and when they left.
*She verified there were not enough columns on the form to document all the controlled medication counts based on the changes in staff as she described.
*She stated that sometimes the nurse and CMA would double sign in a column, but that did not always happen.
*She verified she had already initialed for the 3/10/25 5:00 p.m. controlled medication count record which was prior to the count occurring.
*She verified that there were three staff's initials documented for the 3/11/25 controlled medication count but the current date was 3/10/25.
4. Observation and interview on 3/10/25 at 2:32 p.m. with CMA Z in the medication storage room revealed:
*The controlled medications stored in the medication storage room were to be counted by the nurses when they came on and went off their shifts.
*The controlled medications stored in the medication storage room included:
-Stock controlled medications.
-Residents' controlled medication cards, when the pharmacy dispensed more than one card. The cards not in use would be stored in the medication room until it was needed.
*The Controlled Drug Count Record for the medication storage room was set up the same as the medication carts.
*The March 2025 Med Rm [medication room] Controlled Drug Count Record had no nurse initials for two nurses on 3/1/25, 3/2/25, 3/4/25, 3/7/25, one nurse on 3/10/25.
5. Review of the stock-controlled medication cards and the Individual Patient's Narcotic Record with CMA Z in the medication storage room on 3/10/25 at 2:40 p.m. revealed:
*The Individual Patient's Narcotic Records identified the name of the medication and the dose. In the location designated for a resident's name was stock or Five Counties Stock.
*There was card of Tramadol 50 mg (milligrams).
-The card was received on 1/3/24 with 10 tablets.
-There were six doses removed and signed out to be administered.
--One of those doses did not indicate which resident it was removed for.
--Four doses did not include the year the medication was removed for administration.
*There were two cards of oxycodone (a controlled pain medication)10 mg.
-Oxycodone card one was received on 3/6/23 with 16 tablets.
--Nine doses documented as removed for administration did not indicate which resident it was for.
--Four doses removed for administration did not include the year the medication was removed.
--Two half-tablet documented destructions did not contain a second signature to indicate a licensed staff member witnessed the destruction.
--Two times a CMA was identified as being the witness of the controlled medication destruction.
-Oxycodone card two was received on 7/26/24 with 16 tablets.
--One half-tablet was removed for administration with no documentation of what was done with the remaining half tablet.
--There was one removal for administration that documented the other half was put in lock box for next admin [administration].
--Six administrations did not identify the resident the medication was removed for.
-One time a CMA was identified as being the witness of controlled medication destruction.
*There were three cards of lorazepam (a controlled anti-anxiety medication) 0.5 mg.
-Lorazepam card one was received on 12/30/22 with 16 tablets.
--One dose removed did not identify which resident it was administered to.
--Four times a half tab was administered without documentation of where or how the remaining portion of the tablet was stored for the next administration.
--Fifteen of fifteen of the documented removals for administration did not contain a year the medication was removed.
-Lorazepam card two was received on 12/30/24 with 16 tablets.
--Two of two removals for administrations had not identified the resident the medication was removed for.
-Lorazepam card three did not have an Individual Patient's Narcotic Record. There was a plain white sheet of paper that had handwritten notes of Controlled Drug Record for Lorazepam 0.5 mg tablets Total 16 verified by with a signature following.
--There was no date to indicate when the lorazepam was received.
*There was an opened bottle of liquid lorazepam 2 mg/ml (milligrams per milliliter).
-30 ml was documented as received on 2/20/24.
-14 doses had been removed from the bottle.
-There were three different residents identified that the lorazepam had been removed for.
-Two doses did not indicate the resident the medication was removed for.
6. Review of the provider's February 2025 Controlled Drug Count Records revealed:
*The [NAME] wing Controlled Drug Count Records had a squiggly line drawn through the documentation areas:
-For three nurses' initials on 2/3/25.
-For one nurses' initials on 2/13/25, 2/14/25, and 2/15/25.
-For two nurses' initials on 2/30/25.
*The medication room Controlled Drug Count Record had a squiggly line drawn through the areas for documentation for three nurses on 2/4/25 and two nurses on 2/9/25.
7. Observation and interview on 3/10/25 at 2:47 p.m. with assistant director of nursing (ADON) G in the medication storage room revealed:
*She verified there were missing staff signatures on the March 2025 medication room's Controlled Drug Count Record.
*The Individual Patient's Narcotic Records for the stock medications should have indicated which resident the medications were removed for.
*She verified there were missing resident identifiers on the Individual Patient's Narcotic Records.
*She expected the date the controlled medication was removed from the medication room for administration to be documented in the Individual Patient's Narcotic Records.
*She stated that any nurse or CMA could check-in medications when they were received, including controlled substances.
*The opened bottle of stock liquid lorazepam in the medication room did not have a date to indicate when it was opened.
8. Interview on 3/11/25 at 4:37 p.m. with consultant pharmacist N revealed:
*His role in the facility included managing medication profiles, controlled medication disposal, and to answer staffs' medication related questions.
*The provider received residents' medications from a local pharmacy.
*It was his expectation that each resident's individual controlled drug record be initiated by the pharmacy dispensing the medication and it was to be sent with the medication to the facility.
*He expected controlled medications be delivered by a pharmacist or picked up by a licensed nurse to ensure control and accountability of those high-risk medications.
*It was his expectation that the controlled medications be counted at each shift change by the person coming on a shift with the person leaving a shift.
*The signatures on the Controlled Drug Count Record would indicate the controlled medication counts had been completed and the counts were accurate.
*He indicated the use of a stock supply of controlled medications should not be the process.
-Each card of controlled medications should have been assigned to a specific resident because a hard copy physician prescription would be needed to dispense and administer the medication to the resident.
*He expected that if a half-tablet of a controlled medication was unused it would have been wasted and documented as wasted by a licensed nurse or pharmacist.
9. Interview on 3/12/25 at 1:13 p.m. with director of nursing (DON) B revealed:
*When a resident's-controlled medication was discontinued and was to be destroyed, she and consultant pharmacist N would reconcile the count of the controlled medication and document the medication to be destroyed.
*Consultant pharmacist N destroyed the medications.
*She did not watch the actual destruction of the controlled medications by consultant pharmacist N.
*She thought the Individual Patient's Narcotic Record was initiated at the pharmacy.
*It was her expectation that two staff verify the receipt of controlled medications and both sign the form in verification of that for an accurate count.
*It was her expectation that the controlled medications be counted between each shift by the incoming and off going staff members.
*The signatures on the Controlled Drug Count Record would indicate the counts were completed and accurate.
*She would expect to be notified if there was an issue in the controlled drug counts.
*She agreed there was no column on the Controlled Drug Count Record to account for the controlled medication count with the CMAs.
*It was her expectation that two people witness the destruction of the controlled medications.
*She would expect a date to be documented when controlled medications were removed for administration.
10. Review of the provider's undated Medication Management Policy revealed the following:
*If breaking tablets is necessary to administer the proper dose ., the following guidelines are followed:
-c. If using only one-half of the tablet from a unit dose package, the remainder is disposed of if not used within 24 hours according to facility procedure. If in a vial the half-tablet is returned to the vial.
-Medications supplied for one resident are never administered to another resident.
Review of the provider's undated Pharmacy Services policy revealed the following:
*The facility will provide pharmaceutical services to include procedures that assure [ensure] the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.
*The facility in coordination with the licensed pharmacist, will provide for:
-a. A system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications;
-b. Prompt identification of loss of or potential diversion of controlled medications; and
-c. Determination of the extent of loss or potential diversion of controlled medications.
*The facility will maintain a limited supply of medications for emergency or after-hours situations in accordance with facility policy and applicable state laws.
*The pharmacist, in collaboration with the facility and medical director, may include other aspects of pharmaceutical services such as:
-a. Development of procedures and guidance in relations to medication issues and/or adverse effects;
-b. Development of processes for receiving, transcribing or recapitulation of medication orders;
-c. Interaction with the quality assessment and assurance committee to develop procedures and evaluate pharmaceutical services.
Review of the provider's undated Proper Storage, Usage and Documentation of Narcotics (controlled medications)-policy revealed the following:
*When a narcotic is being accepted, please verify the correct drug and amount. The nurse who accepts the medication should add the count sheet to the narcotic book, notating the date and the time, along with any other needed documentation.
*Access to narcotics is to be by a licensed staff and Director of Nursing ONLY! Scheduled II Narcotics are to be kept locked in a separate are from non-scheduled drugs such as the lock box. Refrigerated scheduled II Narcotics should be stored and locked separately.
*Narcotics are to be counted every shift by nursing staff (AM, PM, NOC). They should not be assumed all accounted for, therefore the nurse going off her shift and the nurse coming on shift should count together and then sign that all narcotics are accounted for.
*When administering narcotics the following should be done:
-After pouring the narcotic, the count should be signed and verified for accurate county [count]. Signing the count sheet does not mean you gave the medication. It is only showing that the count is correct.
-Any refused narcotics that have been poured should not be taped back into the card but should be wasted and disposed of properly.
-There should always be a count sheet for ALL NARCOTICS. If one was not sent from the pharmacy, it can be requested. All count sheets should be used properly, and counts should be accurate. When they are complete the count sheet should be sent to medical records and kept for 3 years.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, record review, interview, and policy review, the provider failed to follow standard food safety practices to ensure:
*The mechanical dishwashers, refrigerator, and freezer temper...
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Based on observation, record review, interview, and policy review, the provider failed to follow standard food safety practices to ensure:
*The mechanical dishwashers, refrigerator, and freezer temperatures were monitored and logged according to their policy.
*Single-use food containers were not used to store leftover food.
*Clean dishes were not stored on frayed cloth towels.
Findings include:
1. Observation on 3/9/25 at 1:59 p.m. in the kitchen revealed the posted dishwasher temperature log for March 2025 was not completed for 3/4/25 through 3/7/25 and 3/9/25.
*The dishwasher temperature logs for January, February, and March 2025 had no temperatures documented on 36 of 67 days.
*The freezer temperature logs for February and March 2025 had no temperatures documented on 15 of 36 days for two of two freezers.
*The walk-in cooler temperature logs for February and March 2025 had no documented temperatures on 8 of 36 days.
*The satellite kitchen refrigerator/freezer temperature logs for February and March 2025 had no temperatures documented on 7 of 31 days.
Interview on 3/11/25 at 4:40 p.m. with dietary manager (DM) D revealed:
*She confirmed the logs were not complete.
*She stated they were working on a new process for the temperature logs.
*She agreed they were not monitoring and recording temperatures according to their policy.
Review of the provider's 1/27/25 Dishwashing Machine Use policy revealed:
*Temperature Records
-The operator will check temperatures using the machine gauge with each dishwashing cycle, and will record the temperatures in a facility approved log.
Review of the provider's 1/8/25 Refrigerator policy revealed:
*Temperatures will be taken twice a day according to staff assignment.
*Staff will record the temperature on a chart.
Interview on 3/11/25 at 4:54 p.m. with administrator A regarding monitoring temperatures of dishwashers, freezers, walk-in coolers, and the satellite kitchen revealed:
*She confirmed there were days the temperatures had not been logged.
-She would have expected those to be completed and logged.
*She confirmed their policies for monitoring the temperatures of dishwashers, freezers, walk-in coolers, and the satellite kitchen were not being followed.
2. Observation on 3/9/25 at 2:05 p.m. in the kitchen revealed:
*The walk-in freezer contained several single-use containers with food items labeled with masking tape which included:
-Two margarine containers labeled pork roast.
--There was no date written on the masking tape.
-A cottage cheese container labeled beef juice 2/17.
-A margarine container labeled beef juice 2/28.
-A vanilla ice cream container labeled chocolate chip cookies 3/3.
*The walk-in refrigerator contained single-use containers with food items that were labeled with masking tape which included:
-A sour cream container covered with cellophane that contained grapes.
-A cottage cheese container labeled peaches 3/9.
-A cottage cheese container labeled applesauce 3/4.
-An additional seven other single-use containers labeled with leftover food items that were dated.
Observation on 3/9/25 at 5:28 p.m. in the dining room revealed that single-use containers were being used to serve leftover food to residents in the dining room.
Interview on 3/11/25 at 11:36 a.m. with DM D about single-use containers revealed:
*She confirmed the containers were single-use containers and should not have been used to store leftover food items.
*She stated she would re-educate staff on not using single-use containers to store leftovers.
Interview on 3/11/25 at 4:51 p.m. with administrator A revealed she was aware that single-use containers were being used for leftover food storage and serving. Those single-use containers should not have been used.
Review of the Administrative Rules of South Dakota (ARSD) 44:02:07:43 revealed:
Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food. Under normal use conditions materials must be safe; durable; corrosion-resistant; nonabsorbent; sufficient in weight and thickness to withstand repeated warewashing; finished to have a smooth, easily cleanable surface; and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
Review of the provider's 1/28/25 Refrigerator Policy revealed:
*It is the intent of [provider] that our residents enjoy a home like atmosphere. We also take all measures to make sure the food they enjoy is safely stored.
-The policy did not address food storage containers.
3. Observation on 3/9/25 at 2:57 p.m. of the kitchen revealed:
*A stainless-steel table was located at the clean end of the area of the dishwasher. On that stainless-steel table was the following:
-A cloth towel that had frayed edges with two coffee carafes and a glass sugar dispenser with no lid stored upside down it.
-There were what appeared to be water calcium spots on that table around the cloth towel.
Observation on 3/11/25 at 11:29 a.m. in the kitchen revealed two frayed wet bath towels on a stainless-steel table with three empty ice-cream buckets and an empty glass sugar dispenser and the lid for it lying on top of the towels.
-There was a clear liquid on the stainless counter that appeared to be water.
Interview on 3/11/25 at 11:36 a.m. with DM D regarding the above observations revealed:
*Towels were placed on the stainless-steel table to keep the water from the wet dishes from dripping onto the floor.
-She agreed the towels were wet and would not have allowed the dishes to air dry.
Interview on 3/11/25 at 4:59 p.m. with administrator A regarding the use of cloth towels in the kitchen revealed she was not aware that cloth towels should not have been used to store wet dishes on.
Review of the Food and Drug Administration Food Code 2022 revealed:
*Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS:
-Shall be air-dried or used after adequate draining
-May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry.
Review of the ARSD for Lodging and Food Service revealed:
*Cleaned equipment and utensils must be stored as follows:
-In a clean, dry location;
-Where they are not exposed to splash, dust, or other contamination;
-In a self-draining position that permits air drying; and
-Either covered or inverted.
*After sanitizing, equipment and utensils must be air-dried or may be used after adequate draining.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered by administrator A, director of nurs...
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Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered by administrator A, director of nursing (DON) B, and assistant director of nursing (ADON) G, in a manner that ensured quality of life and overall well-being for all 39 residents in the facility.
Findings include:
1. Observations, interviews, record reviews, and policy reviews throughout the survey on 3/9/25 from 1:00 p.m. through 6:00 p.m., 3/10/25 from 7:30 a.m. through 6:15 p.m., 3/11/25 from 7:00 a.m. through 6:00 p.m., and 3/12/25 from 7:30 a.m. through 5:30 p.m., revealed administrator A, DON B, and ADON G, had not ensured the management, safety, quality of life, and overall well-being of all the residents who lived in the facility. Those were evidenced by:
*A widespread system breakdown to ensure services provided:
-Met professional standards as it pertained to:
--Medication administration and storage.
--Addressing and notifying the physician of the significant weight loss for one resident (36).
--Identifying and addressing low blood sugars for one diabetic resident (5).
-Met the requirements for sufficient nursing staff including:
--Full-time DON.
--Registered nurse coverage for eight hours each day.
--Twenty-four-hour licensed nurse coverage.
--The daily posting of nurse staffing.
-Addressed trauma informed care.
-Monitored for appropriate temperatures of mechanical dishwashers, refrigerators and freezers in the kitchen.
-Addressed appropriate storage of leftover food.
-Allowed for residents' and their representatives' right to make informed decisions and choices about important aspects of residents' health, safety, and welfare related to binding arbitration agreements to resolve disputes.
-Included providing a written summary of the baseline care plan within 48 hours of a resident's admission.
-Included a preventative maintenance program for the safe use of resident side rails.
*Ensuring the proper Medicare notices were completed accurately for three residents (10, 33, and 41) prior to their discharge from Medicare Part A skilled services.
*Responding to a resident's (5) concern with a staff member, certified nursing assistant R.
*Ensuring privacy and signage had been maintained for two residents (9 and 21) with audio/video monitoring devices in their rooms.
*Implementing an effective performance improvement plan and quality assurance program.
2. Review of the provider's undated job description for the administrator revealed:
*Summary: Administers, directs and coordinates all activities of the care center to carry out its objectives as to the care of the individuals who need nursing care .
*Essential Duties included:
-Coordinates and integrates the total overall program of the facility.
-Make sure residents are meeting their highest level of professional care needed.
-Develops and monitors all departments within the facility to meet the standards put forth by the governing board, management, and state and federal regulations.
Review of the provider's 10/30/15 job description for the director of nursing revealed:
*Summary: This individual directs the licensed and non-licensed staff who provide health care and nursing services to residents of the facility. The Director of Nursing's primary responsibility is to ensure the provision of quality nursing care on a 24-hour basis to the residents of the care center in accordance with Federal, State and Local standards and regulations.
*Essential Duties included:
-Monitors the staffing levels of various nursing sections .
-Develops and directs nursing services objectives, policies and procedures.
-Assures that there is compliance with the regulations pertaining to care plans and resident assessments.
-Collaborates with outside providers such as . pharmacy companies to enhance the quality of care for the residents.
Refer to F582, F583, F610, F655, F658, F699, F700, F725, F727, F732, F755, F761, F812, F847, F865, and F909.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
Based on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being...
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Based on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all 39 residents in the facility.
Findings include:
1. During the survey on 3/9/25 from 1:00 p.m. through 6:00 p.m., 3/10/25 from 7:30 a.m. through 6:15 p.m., 3/11/25 from 7:00 a.m. through 6:00 p.m., and 3/12/25 from 7:30 a.m. through 5:30 p.m., it was identified that the provider had not operated in a manner to ensure residents received quality care. Administrator A had not been assisted with her duties to ensure she was able to effectively provide guidance to staff to be able to provide quality care. Those were evidenced by:
*A widespread system breakdown to ensure services provided:
-Met professional standards as it pertained to:
--Medication administration and storage.
--Addressing and notifying the physician of the significant weight loss for one resident (36).
--Identifying and addressing low blood sugars for one diabetic resident (5).
-Met the requirements for sufficient nursing staff including:
--Full-time DON.
--Registered nurse coverage for eight hours each day.
--Twenty-four-hour licensed nurse coverage.
--The daily posting of nurse staffing.
-Addressed trauma informed care.
-Monitored for appropriate temperatures of mechanical dishwashers, refrigerators and freezers in the kitchen.
-Addressed appropriate storage of leftover food.
-Allowed for residents' and their representatives' right to make informed decisions and choices about important aspects of residents' health, safety, and welfare related to binding arbitration agreements to resolve disputes.
-Included providing a written summary of the baseline care plan within 48 hours of a resident's admission.
-Included a preventative maintenance program for the safe use of resident side rails.
*Ensuring the proper Medicare notices were completed accurately for three residents (10, 33, and 41) prior to their discharge from Medicare Part A skilled services.
*Responding to a resident's (5) concern with a staff member, certified nursing assistant R.
*Ensuring privacy and signage had been maintained for two residents (9 and 21) with audio/video monitoring devices in their rooms.
*Implementing an effective performance improvement plan and quality assurance program.
Refer to F582, F583, F610, F655, F658, F699, F700, F725, F727, F732, F755, F758, F761, F812, F835, F847, F848, F851, F865, and F909.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and Arbitration Agreement review, the provider failed to ensure seven of thirteen sampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and Arbitration Agreement review, the provider failed to ensure seven of thirteen sampled residents (13, 21, 23, 24, 25, 36, and 142) and three of three recently admitted residents (38, 39, and 142) who had entered into an Arbitration Agreement upon admission to the facility:
*Were not required to sign a binding arbitration agreement as a condition of admission to receive care at the facility.
*Were explained the arbitration agreement in a form and manner including a language that the resident or his/her representative understood.
*Were explicitly granted the right to rescind the agreement within 30 calendar day of signing it.
Findings include:
1. Record review on 3/10/25 at 1:00 p.m. of the Resident List Report printed at 12:10 p.m. that day by administrator A revealed:
*The report listed forty residents which included thirty-nine residents in the facility and one resident who was hospitalized .
*A handwritten note by administrator A that indicated All residents have a signed arbitration agreement. No active disputes.
2. Interview on 3/10/25 at 4:28 p.m. with resident 38 in his room regarding the Arbitration of Disputes admission agreement addendum he had signed on 2/13/25 revealed:
*He did not recall signing any admission documents and asked if he had signed it or one of his kids?
*After showing him a copy of the signed one-page Arbitration of Disputes and asking him if he remembered signing that document he stated Not at all.
-After reviewing his signature, he agreed he had signed that agreement.
-He could not remember what the agreement was about.
Review of resident 38's electronic medical record (EMR) revealed:
*He was admitted on [DATE].
*His 2/13/25 admission agreement was signed by resident 38, his son/durable power of attorney (DPOA)/DPOA healthcare (DPOA-HC), and administrator A.
-The admission Agreement Addendum included the one-page Arbitration of Disputes dated 2/13/25 that was signed by the resident.
--The resident's son/DPOA/DPOA-HC had not signed this agreement.
*His 2/18/25 brief interview for mental status (BIMS) assessment score was 12, which indicated his cognition was moderately impaired.
3. Review of resident 142's EMR revealed:
*She was admitted on [DATE].
*Her 3/3/25 admission agreement was signed by her daughter/DPOA/DPOA-HC, and social services director (SSD) E.
-The admission Agreement Addendum included the one-page Arbitration of Disputes dated 3/3/25 that was signed by the resident's daughter/DPOA/DPOA-HC.
*Her 3/4/25 BIMS assessment score was 14, which indicated she was cognitively intact.
Phone interview on 3/10/25 at 4:50 p.m. with resident 142's daughter/DPOA/DPOA-HC regarding the Arbitration of Disputes admission agreement addendum she had signed on 3/3/25 revealed she:
*Could not recall understanding the arbitration process and stated:
-She would discuss anything that wasn't right with the provider.
-I didn't think we were totally giving up the right to litigate in a court proceeding.
*Had No idea [what she was signing] as that was a very stressful day.
*Could not remember if her right to terminate or withdraw from the agreement within 30 days of signing had been discussed.
*Stated admitting her mother to the facility had been a long day and there was a lot of paperwork.
4. Review of resident 39's EMR revealed:
*She was admitted on [DATE].
*Her 2/26/25 admission agreement was signed by her daughter/DPOA/DPOA-HC, and SSD E.
-The admission Agreement Addendum included the one-page Arbitration of Disputes dated 2/26/25 that was signed by the resident's daughter/DPOA/DPOA-HC.
*Her 3/4/25 BIMS assessment score was 13, which indicated she was cognitively intact.
Phone interview on 3/10/25 at 5:04 p.m. with resident 39's daughter/DPOA/DPOA-HC regarding the Arbitration of Disputes admission agreement addendum she had signed on 3/3/25 revealed she:
*Was at work, but was able to answer a few questions.
*Could not recall what the arbitration agreement was about.
*Felt it was a form that needed to be signed.
5. Review of resident 25's EMR revealed:
*He was admitted on [DATE].
*His 8/29/24 admission agreement was signed by his niece/responsible party and SSD E.
-The admission Agreement Addendum included the one-page Arbitration of Disputes dated 8/29/24 that was signed by the resident's niece/responsible party.
*His 9/5/24 BIMS assessment score was 8 which indicated his cognition was moderately impaired.
6. Review of resident 13's EMR revealed:
*She was admitted on [DATE].
*Her 11/27/24 admission agreement was signed by her son/DPOA/DPOA-HC, and SSD E.
-The admission Agreement Addendum included the one-page Arbitration of Disputes dated 11/27/24 that was signed by the resident's son/DPOA/DPOA-HC.
*Her 12/3/24 BIMS assessment score was 12 which indicated her cognition was moderately impaired.
7. Review of resident 36's EMR revealed:
*She was admitted on [DATE].
*Her 1/28/25 admission agreement was signed by her daughter/DPOA and SSD E.
-The admission Agreement Addendum included the one-page Arbitration of Disputes dated 1/28/25 that was signed by the resident's daughter/DPOA.
*Her 2/4/25 BIMS assessment score was 7 which indicated her cognition was severely impaired.
8. Interview on 3/10/25 at 5:10 p.m. with SSD E regarding the one-page Arbitration of Disputes form revealed:
*The form was included in the admission agreement binder that included the paperwork the resident and/or representative signed upon admission.
*She had not had anyone refuse to sign it.
*She had no training on the form or how to discuss the agreement with the resident and/or representative on admission.
*She had not ensured the person signing the form understood their right:
-To refuse to enter into an arbitration agreement.
-To rescind the agreement within 30 days of signing that form.
*She stated she treated the form as informational acknowledgment and not as an agreement.
*Her responsibilities included having the resident and/or representative sign the admission Agreement paperwork.
-For most admissions, while the resident was involved with the nurse's physical assessment, she would have the representative complete the admission paperwork.
--That is what had happened with residents 39 and 142 noted above.
-If she was unavailable, Administrator A would fill-in and complete the resident's admission agreement paperwork with the resident and/or representative.
--She was not available on 2/13/25, when resident 38 had admitted to the facility.
--Administrator A had completed the admission paperwork for resident 38's admission.
Interview on 3/10/25 at 5:43 p.m. with administrator A revealed:
*SSD E completed the admission paperwork with most of the residents' admissions.
-She assumed SSD E discussed the arbitration agreement appropriately with residents and/or representatives.
*She agreed she had completed the admission paperwork for resident 38 on 2/13/25.
-She stated resident 38, his daughter, his son/DPOA/DPOA-HC, and his son's wife were all present when the admission paperwork was completed.
-She confirmed that this admission agreement was signed by resident 38, his son/DPOA/DPOA-HC, and administrator A.
-She stated resident 38's son/DPOA/DPOA-HC read the paperwork prior to signing.
--Resident 38's family read the arbitration agreement and stated resident 38 could sign that agreement.
--Resident 38 was not really interested in reading the arbitration agreement and had commented You just want my signature.
Interview and record review of the undated one-page Arbitration of Disputes admission Agreement Addendum on 3/11/25 at 8:24 a.m. with administrator A revealed:
*The arbitration agreement was reviewed to ensure it clearly stated that the resident or his or her representative was not required to enter into the agreement as a condition of admission to the facility.
-Administrator A agreed that was not clearly stated in the agreement.
-Administrator A stated it was a poorly written agreement.
Further interview that day with administrator A at 8:30 a.m. after reviewing the requested arbitration agreements for three residents (21, 23, and 24) and a handwritten note from SSD E revealed:
*On 11/8/22, SSD E was provided notice to add the Arbitration of Disputes form to the admission Agreement packet.
*Administrator A confirmed that residents who were admitted to the facility prior to 11/8/22 had not entered into the arbitration agreement.
Interview on 3/11/25 at 9:51 a.m. with SSD E regarding requested arbitration agreements revealed:
*She confirmed that prior to 11/8/22 the residents admitted to the facility had not signed an arbitration agreement upon their admission.
*Those residents had not been asked to sign the arbitration agreement after 11/8/22, when the arbitration agreement was added to the admission agreement packet.
*A printed email, that she provided, indicated on 11/8/22 at 1:48 p.m. the administrator of the facility, at that time, had e-mailed the Arbitration of Disputes as an attachment with the message Please include this in your admission packet.
-She confirmed that was her notice and that she had received no training on that form or the arbitration process.
Interview on 3/11/25 at 1:10 p.m. with administrator A regarding the requested policy on arbitration agreements revealed the provider did not have such a policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0848
(Tag F0848)
Could have caused harm · This affected most or all residents
Based on interview and Arbitration Agreement review, the provider failed to ensure the provider's Arbitration Agreement:
*Included the arbitration organization's name and how to contact that organizat...
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Based on interview and Arbitration Agreement review, the provider failed to ensure the provider's Arbitration Agreement:
*Included the arbitration organization's name and how to contact that organization.
*Provided for the selection of a neutral arbitrator agreed upon by both parties.
*Provided for a location that was convenient for both parties for an arbitration dispute.
Findings include:
1. Interview and record review of the provider's one-page arbitration agreement on 3/10/25 at 5:43 p.m. with administrator A revealed that the agreement had not included:
*The arbitration organization's name and how to contact that organization.
*For the provision of the selection of a neutral arbitrator agreed upon by both parties.
*For the provision of a location that was convenient for both parties for an arbitration dispute.
*Administrator A agreed with those findings above.
Interview on 3/11/25 at 1:10 p.m. with administrator A regarding the arbitration agreement revealed:
*The provider had no policy regarding arbitration agreements.
*She agreed the arbitration agreement was poorly written.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on Payroll Based Journal (PBJ) record review, employee timecard review, and interview, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters reviewed Quart...
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Based on Payroll Based Journal (PBJ) record review, employee timecard review, and interview, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters reviewed Quarter 2, 2024 (January 1 through March 31, 2024); Quarter 3, 2024 (April 1 through June 30, 2024)2024); and Quarter 4, 2024 (July 1 through September 30, 2024).
Findings include:
1. Review of the PBJ records submitted to the Center for Medicare and Medicaid Services (CMS) revealed the provider submitted the following for licensed nursing coverage not being covered 24 hours per day for:
*Quarter 2, 2024 for 34 days.
*Quarter 3, 2024 for 11 days.
*Quarter 4, 2024 for 30 days.
2. Review of the PBJ records submitted to CMS revealed the provider submitted the following for RN (registered nurse) coverage for 8 consecutive hours per day for:
*Quarter 2, 2024 for 16 days.
*Quarter 4, 2024 for 4 days.
3. Review of the provider's employee timecards revealed:
*Quarter 2, 2024; 24-hour licensed nursing coverage was verified for 13 of the 34 days that were triggered for no 24-hour licensed nursing coverage and for 12 of the 16 days triggered for no RN coverage for 8 consecutive hours per day.
*Quarter 3, 2024; 24-hour licensed nursing coverage was verified for 6 of the 11 days that were triggered for no 24-hour licensed nursing coverage.
*Quarter 4, 2024; 24-hour licensed nursing coverage was verified for 16 of the 30 days that were triggered for no 24-hour licensed nursing coverage and for all the days triggered for no RN coverage for 8 consecutive hours per day.
*The timecard information supported the PBJ records were not accurate.
4. Interview on 3/10/25 at 6:03 p.m. with business office manager C regarding PBJ data submission revealed:
*She was responsible for submission of the PBJ data.
*She stated she entered the travel staff hours worked manually into the PBJ and the other staff hours worked were transferred electronically from their timecards into the PBJ online reporting system.
*She was aware there were days on the PBJ reports that indicated there was no 24-hour licensed nursing coverage and no RN coverage for 8 consecutive hours per day.
*She did not know how there was missing data because with each submission she received an indicator that 100% of the information was submitted and the report had been accepted.
-She was not aware that the indicator only provided notification that the information submitted was accepted at 100% and not if that data was accurate to actual hours worked by staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview, and quality assurance and performance improvement (QAPI) plan policy review, the provider failed to ensure they had identified and corrected quality deficiencies when they occurred...
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Based on interview, and quality assurance and performance improvement (QAPI) plan policy review, the provider failed to ensure they had identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, or monitored regarding nurse staffing, siderails, medication administration and storage, baseline care plans, and arbitration agreements.
Findings include:
1. Interview on 3/12/25 at 11:29 a.m. with administrator A regarding the QAPI program and committee revealed:
*She was the QAPI coordinator for the provider and stated each department manager conducted their own audit, discussed that audit with the QAPI committee, and implemented any plan needed for correction.
*The provider's QAPI committee was comprised of:
-All the department managers.
-Administrator A.
-Director of nursing (DON) B.
-The following committee members attended on a quarterly basis:
--The medical director.
--The executive director.
--The consultant dietitian (by phone).
*The QAPI committee was currently working on projects that included new carpet for the facility, new dining room chairs, and new activity room chairs.
*The QAPI committee's current performance improvement project (PIP) was aimed at improvements regarding residents at risk for or experiencing weight loss.
*Regarding areas of non-compliance identified by the survey team that included:
-Staffing concerns related to a full-time DON, registered nurse (RN) coverage for at least eight hours a day, licensed nurse coverage 24 hours a day, and the required posting of that nurse staffing information.
--She stated they were in a transition period from the previous full-time DON who was employed at the facility from 7/1/24 to 1/31/25.
--DON B was currently mentoring assistant DON (ADON) G to assist with the DON role.
--She stated the QAPI committee had not addressed the required full-time director of nursing position.
-The three days during January and February 2024 with no RN hours was during a transition period.
-The numerous days without licensed nurse coverage 24 hours a day was due to a documentation error.
--She stated the QAPI committee was not aware of those issues.
-Bedrail concerns related to assessments; lack of consents; and lack of a preventative and safety maintenance program ensuring the safe use of those bedrails.
--She stated the QAPI committee was not aware of those issues.
-Medication administration and storage concerns related to receipt, administration, accountability, storage, labeling, and destruction of medications.
--She stated the QAPI committee was not aware of those issues.
-Baseline Care Plan concerns related to providing those to the resident/representative within 48 hours of admission.
--She stated the QAPI committee was not aware of those issues.
-Arbitration agreements concerns.
--She stated the QAPI committee was not aware of those issues.
-She confirmed their QAPI process had not been effective in identifying these quality issues that could have impacted the resident's care.
2. Review of the provider's 6/25/24 QAA (Quality Assessment and Assurance) Committee Policy revealed:
*Intent: These policies are intended to ensure that [Name of Provider] develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety.
*The policy indicated the QAA committee would:
-Develop and implement appropriate plans of action to correct identified quality deficiencies.
-The quality assessment and assurance committee reports to the facility's governing body, or designated person (Administrator).
Review of the provider's 7/31/24 QAPI Plan revealed:
*The QAPI program will aim for safety and high quality with all clinical interventions and service delivery . by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action.
*The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions .
*The governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program .
Refer to F655, F700, F725, F727, F732, F755, F761, F847, F848, F851, and F909.
Jan 2025
1 deficiency
CONCERN
(E)
📢 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of SD DOH complaint report submitted on 1/15/25 at 4:53 p.m. revealed:
*The complainant wished to remain anonymous.
*T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of SD DOH complaint report submitted on 1/15/25 at 4:53 p.m. revealed:
*The complainant wished to remain anonymous.
*The complainant reported concerns with the accuracy of resident assessments and timeliness of the documentation of resident assessments at the facility.
3. A review of resident 2's electronic medical record (EMR) revealed:
*Her diagnoses included secondary hypertension (high blood pressure from an underlying medical condition), hyperlipidemia (high cholesterol), chronic obstructive pulmonary disease (COPD), anemia, peripheral vascular disease (progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel), and essential hypertension (the most common type of high blood pressure).
*Previous vital signs were documented instead of having checked and documented her current vital signs each day. From 10/4/24 to 11/12/24, her:
- Blood pressure was checked on 33 out of 41 days.
- Pulse was checked on 24 out of 41 days.
- Temperature was checked on 25 out of 41 days.
- Respirations were checked on 24 out of 41 days.
-Oxygen saturation was checked on 26 out of 41 days.
4. A review of resident 3's EMR revealed:
*Her diagnoses included COPD, atrial fibrillation (a condition that causes an irregular heartbeat), secondary hypertension, weakness, and essential hypertension.
*Previous vital signs were documented instead of having checked and documented her current vital signs each day. From 10/1/24 to 10/29/24, her:
- Blood pressure was checked on 11 out of 29 days.
- Pulse was checked on 11 out of 29 days.
- Temperature was checked on 10 out of 29 days.
- Respirations were checked on 11 out of 29 days.
- Oxygen saturation was checked on 12 out of 29 days.
5. A review of resident 4's EMR revealed:
*Her diagnoses included severe chronic kidney disease, heart failure, essential hypertension, Type 2 Diabetes, peripheral vascular disease, and chronic myeloproliferative disease (rare blood cancers).
*Previous vital signs were documented instead of having checked and documented her current vital signs each day. From 11/26/24 to 12/24/24, her:
- Blood pressure was checked on 20 out of 29 days.
- Pulse was checked on 20 out of 29 days.
- Temperature was checked on 19 out of 29 days.
- Respirations were checked on 20 out of 29 days.
- Oxygen saturation was checked on 20 out of 29 days.
6. A review of resident 5's EMR revealed:
*Her diagnoses included dementia, adult failure to thrive, acute kidney failure, heart failure, muscle weakness, and other specified disorders involving the immune mechanism.
*Previous vital signs were documented instead of having checked and documented her current vital signs each day. From 9/18/24 to 10/17/24, her blood pressure, pulse, temperature, respirations, and oxygen saturation were checked on 13 out of 29 days.
7. A review of resident 6's EMR revealed:
*His diagnoses included essential hypertension, diabetes mellitus due to underlying condition, and 2-part displaced fracture of surgical neck of left humerus (upper part of the left humerus bone near the shoulder has fractured into two pieces that are significantly displaced).
*Previous vital signs were documented instead of having checked and documented his current vital signs each day. From 12/13/24 to 1/20/25, his blood pressure, pulse, temperature, respirations, and oxygen saturation were checked on 26 out of 38 days.
8. Interview with Nurse Executive/Director of Nursing (DON) B revealed she agreed that a current set of a resident's vital signs needed to be a part of a skilled nursing assessment. She stated, I assume it is just pulling from the last documented vital signs if they aren't entering current vitals.
9. Review of the provider's undated How to Chart on Medicare A Residents policy revealed:
* What do you need?
- Full set of vitals on the resident (BP, Pulse, Temp, O2 Sat, RR [respiratory rate]).
* How Often Do I need to do this charting?
- For Medicare to reimburse us for services, we need to do this charting every 24 hours.
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), complaint report, record review, interview, and policy review, the provider failed to ensure:
*They had followed their policy after one of one sampled resident (1) who had fallen and was not referred to therapy after those falls.
*Assessments accurately reflected a resident's status for five of five sampled residents (2, 3, 4, 5, 6). Specifically, the provider failed to assess vital signs and ensure that vital signs were documented accurately on skilled nursing assessments.
Findings included:
1. Review of the provider's SD DOH FRI submitted on 1/7/25 at 12:38 p.m. regarding resident 1 revealed:
*Staff assisted the resident to the bathroom, gave her the call light, remindered her to ring the call light when she was done and left to help another resident.
*Staff had heard resident 1 calling for help and found her on the bathroom floor with her pants and incontinence pull-up down, sitting on her bottom with her right arm in the wheel of the wheelchair (wc) and her left arm behind her to support herself.
*Staff had moved the wc and did a quick assessment, then moved the resident to the wc where the registered nurse completed a full assessment.
-Redness noted to buttock where she was sitting on the floor, some redness noted to leftunderarm [left under arm] (resident states this is from bars on the side of toilet).
-Resident is c/o [complaining of] pain in left ankle. Mild redness noted there and some puffiness, much like the right ankle and CNA [certified nursing assistant] reports it may have been like that prior to fall.
*At 5:00 am, resident continues to complain of left ankle pain an ER [emergency room] physician notified.
*Resident was transported to the clinic for a physician ordered x-ray which determined a non-displaced fracture.
Review of resident 1's electronic medical record (EMR) revealed:
*She was admitted to the facility on [DATE].
*Her diagnoses included: chronic systolic heart failure, diabetes, macular degeneration, hypertension, and muscle weakness.
*She had started physical therapy (PT) on 5/22/24. Her PT Assessment indicated:
-Her therapy diagnosed included: a history of falls, risk of falls, weakness, and imbalance.
-She required the use of a a sit-to-stand (mechanical lift used to assist from a seated to standing position) supervision or minimal assistance. For chair-to-bed or chair-to-chair transfers, she required moderate staff assistance. For toilet transfers, she required moderate staff assistance.
*She was discharged from PT servoces on 6/19/24.
*Her PT discharge assessment indicated:
-For the chair-to-bed or chair-to-chair transfers, she required staff supervision or minimal assistance. For toilet transfers, she required staff supervision or minimal assistance.
-She was to have restorative therapy for ambulation, transfers, and active range of motion (AROM) for upper and lower extremities, three to five times a week.
*Minimum Data Set (MDS) review note from PT on 8/22/24 stated: [resident 1] uses a w/c for mobility around the facility. She is refusing to ambulate. She is requires mod [moderate] assistance in transfers. She is on a walk-to dine and AROM. Restorative programs atthis [at this] time. No therapy indicated at this time.
*She had fallen on 8/27/24, 10/20/24 and 1/4/25.
*The falls event checklist related to her falls on 8/27/24 and 10/20/24 did not have the therapy department box checked as notified.
*After her 8/27/24 and 10/20/24 falls, there was no documention that indicated physical therapy was notified or a therapy referral was sent.
-Death in the facility on 1/19/25.
Interview on 1/22/25 at 10:45 a.m. with physical therapist C revealed:
*He was one of two physical therapist who were employed with the facility.
*He was unaware of any referrals sent to the physical therapy department for resident 1 after she had fallen on 8/27/24 or 10/20/24.
*He stated if the therapy department had gotten a referral there would have been documentation in the resident's chart.
-There was no documentation in resident 1's chart for a therapy referral or therapy services after she had fallen.
Interview on 1/22/25 at 2:05 p.m. with director of nursing (DON) B revealed:
*She was unaware a referral had not been sent to the therapy department after resident 1 had fallen on 8/27/24 and 10/20/24.
*She was not sure why the therapy department was not notified.
*She confirmed the therapy department notifiation box on the falls event checklist for resident 1's falls on 8/27/24 and 10/20/24 were not check marked.
Review of the provider's reviewed December 2024 Fall policy revealed:
*Purpose: To provide a safe living environment for residents and to protect them from injury.
*Post-Fall Management:
-PT will be notified of each fall as it occurs. Referrals for evaluation made as indicated.
Dec 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review, interview, and policy review, the provider failed to ensure the bed hold notice was given upon the transfer on three separate dates for one of one sampled resident (10) to the ...
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Based on record review, interview, and policy review, the provider failed to ensure the bed hold notice was given upon the transfer on three separate dates for one of one sampled resident (10) to the hospital. Findings include:
1. Review of resident 10's electronic medical record (EMR) revealed:
*On 3/30/23, he had been transferred to the hospital when staff was unable to keep his oxygen saturation levels above 90% on eight liters of oxygen.
*On 4/6/23, he was transferred to the hospital at the request of his family representative when he had lost consciousness while transferring using a mechanical stand lift.
*On 11/19/23, he was transferred to the hospital for intravenous (IV) antibiotics to treat cellulitis in his left leg.
The bed hold forms were requested on 12/5/23 at 3:15 p.m. for the above three hospital transfers and the facility was not able to produce that documentation.
Interview on 12/06/23 at 9:49 a.m. with interim director of nursing B revealed:
*Her expectation would have been that all residents who were transferred out of the facility to an acute care provider would be given the bed hold policy and form by the nurse on duty at the time of transfer.
*She would expect any resident that was unable to sign the bed hold policy at the time of the transfer, should have been given the bed hold policy and form to sign at the earliest possible time, or the policy should have been given to the resident's representative to read and sign.
Review of the provider's undated BED HOLD POLICY form revealed:
*POLICY
-Five Counties will provide written information to the resident and a family member of legal representative of our Bed Hold Policy at the time of transfer to an acute care hospital or on therapeutic leave.
*PROCEDURE
-The Charge Nurse at the time of transfer will provide a copy of the Bed Hold Policy to the resident or family member/responsible party.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on review of the Consultant Pharmacist Review reports for 2023, record review, and interview, the provider failed to ensure a physician's order included a specific duration of time for an as nee...
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Based on review of the Consultant Pharmacist Review reports for 2023, record review, and interview, the provider failed to ensure a physician's order included a specific duration of time for an as needed (PRN) psychotropic medication for one of one sampled resident (1) who received a PRN psychotropic medication. Findings include:
1. Review of resident 1's electronic medical record (EMR) and paper chart revealed:
*Consultant Pharmacist Review 2023 monthly notes completed by pharmacist H regarding his review of the resident's medical record for identification of medication irregularities.
*His September 2023 review note was dated 9/30/23:
-MD [medical doctor] - Serax (a psychotropic medication) DR [dose reduction] request - now taking prn for insomnia (as of 10/31/23) - no need to send.
*His October 2023 note was dated 10/31/23:
-No recommendations.
*A Fax Communication to Provider form dated 10/31/23: Resident was out of oxazepam [Serax] over the weekend. She reports that she did 'well without it' and is requesting it be changed to PRN. Resident noted to be well and in good spirits during evening hours at that time.
*The physician responded to that fax on 10/31/23 with new orders to change the frequency of administering the Serax from once daily at night to PRN every 24 hours.
-There was no end date for the duration of time that the medication was expected to have been administered.
*Medication Administration Records revealed the resident had used that PRN Serax 18 of 30 days during November 2023 and twice between 12/1/23 and 12/3/23.
Telephone interview on 12/5/23 at 3:30 p.m. with pharmacist H regarding the physician-ordered Serax frequency changes referred to above revealed he:
*Had known PRN orders for the use of psychotropic medications were limited to 14 days unless the physician documented a rationale to extend the use of that medication.
*Should have requested a standing order for re-evaluation of the use of that medication every 14 days or requested the medication to have been administered on a scheduled basis.
A PRN Psychotropic Medication policy was requested from interim director of nursing B (DON) on 12/5/23 at 3:00 p.m. On 12/6/23 at 9:00 a.m. Interim DON B stated the provider had no policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 12/4/23 at 3:20 p.m. of resident 14 revealed:
*He was sitting in his wheelchair in the dayroom watching televi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 12/4/23 at 3:20 p.m. of resident 14 revealed:
*He was sitting in his wheelchair in the dayroom watching television.
*He had a chair alarm device connected to the back of his wheelchair.
Review of resident 14's EMR revealed:
*He was admitted on [DATE].
*His 12/5/23 BIMS score was 5 indicating he had severe cognitive impairment.
*His diagnosis included vascular dementia with other behavioral disturbances.
*He was at high risk for falls and was an elopement risk related to cognitive limitations.
Review of resident 14's revised 12/5/23 care plan revealed:
*A chair alarm device was in place due to his high fall risk.
*Staff were to ensure the device was in place.
Interview on 12/6/23 at 10:03 a.m. with CNA M revealed:
*She was not aware when a resident would need a chair alarm device unless she checked the resident's care plan.
*She was not responsible for charting the use of the chair alarms in the EMR.
-The nurses were responsible for the monitoring and documentation of the chair alarm devices.
Interview on 12/6/23 at 10:10 a.m. with LPN F revealed he:
*Would not have been aware that a resident needed a chair alarm device unless he checked the resident's care plan.
*Would visually monitor the resident if they used a chair alarm device.
*Had been unsure if there was a place to document the use or the monitoring of a chair alarm device in the EMR.
Interview on 12/6/23 at 10:15 a.m. with interim DON B regarding resident 14's chair alarm device revealed:
*The nurses were responsible for adding physician ordered chair alarms into the resident's TAR.
-Monitoring the use and continued necessity of a chair alarm device was expected to have been documented daily on the TAR.
*Her review of resident 14's December 2023 TAR revealed no documentation related to the chair alarm device.
Review of the provider's 6/1/21 Miscellaneous Nursing Interventions policy revealed:
*Chair alarm device documentation was expected to have been completed once each 12 hour shift on the TAR.
-That documentation would have included the chair alarm device was used appropriately and if any falls had occurred.
2. Observation and interview on 12/04/23 at 4:31 p.m. with resident 11 revealed:
*He had a urine drainage bag that was visible under his pant leg.
-He had been in the hospital and had a suprapubic catheter placed at that time.
*The certified nursing assistants (CNAs) emptied the urine drainage bag several times a day.
*He could not remember if the nursing staff cleaned the suprapubic catheter insertion site or placed a dressing on the site.
*He had a history of urinary tract infections (UTIs).
Review of resident 11's EMR revealed:
*He had a Brief Interview for Mental Status (BIMS) score of 13 indicating he was cognitively intact.
*His diagnosis included benign prostatic hyperplasia (BPH) with lower urinary tract symptoms.
*Review of his 10/12/23 revised care plan revealed:
-He had a suprapubic urinary catheter placed on 10/11/23 related to BPH with obstructive uropathy.
-He wore a urine drainage bag.
-He required staff assistance for his suprapubic catheter care including a daily dressing change.
*Review of active physician's orders related to his suprapubic catheter revealed:
-A urinalysis (UA) was ordered on 12/4/2023 and the lab result indicated the resident had a UTI.
-A 10/16/23 hospital discharge order: Keep suprapubic catheter area clean and dry and change dressings as needed.
*A 10/16/23 skin/wound note documenting a dressing was changed around the suprapubic site.
-There was no documentation regarding other dressings or suprapubic catheter care at the insertion site in the EMR.
*Review of the October 2023 through December 2023 Treatment Administration Record (TAR) revealed:
-No physician's order for care of the suprapubic catheter insertion site.
-No care of the insertion site was documented.
Interview on 12/05/23 at 4:20 p.m. with LPN F regarding resident 11 revealed:
*He was hospitalized and had a suprapubic catheter inserted on 10/11/23.
*The suprapubic catheter was inserted due to his history of urinary tract infections and a urethral blockage that had caused trauma when a Foley catheter was inserted.
*He had a 12/4/23 UA and the lab results indicated the resident had a UTI.
*The CNAs emptied the resident's urine drainage bag each shift and as needed.
*The nursing staff was responsible to clean the suprapubic catheter and should have placed a split gauze at the insertion site.
*Suprapubic catheter care should have been performed and then documented on the TAR.
*The resident had not received suprapubic catheter care.
*The nursing staff should have followed the hospital discharge orders for the suprapubic catheter care and the nurse who entered the hospital discharge orders had not added that physician's order to the TAR.
*He agreed that not regularly performing suprapubic catheter care at the insertion site might have contributed to the resident's UTI.
Observation and interview on 12/05/23 at 4:33 p.m. with CNA G emptying resident 11's urine drainage bag revealed:
*The CNAs empty his urine drainage bag each shift and as needed.
*She reported any urine or catheter concerns to the nurse.
*CNAs would not complete insertion site care for residents with suprapubic catheters.
-The nurses were responsible for completing that care.
Interview on 12/06/23 at 10:01 a.m. with interim DON B regarding suprapubic catheter care revealed:
*She reviewed the suprapubic catheter care policy with the nursing staff, and provided education on suprapubic catheter care for the nursing staff when the resident returned from the hospital.
*They received a 10/16/23 physician's order for suprapubic catheter care when the resident was discharged from the hospital, and that care was not documented on his TAR.
*She expected nursing staff to follow the hospital discharge physician orders for suprapubic catheter care and the nurse who had received those orders enter them into the TAR.
*She believed despite the suprapubic catheter care not being documented on the TAR the resident's suprapubic catheter care was being completed sporadically.
*She had found only one skin/wound note dated 10/16/23 in the EMR that documented a dressing was changed around the suprapubic site.
*She agreed suprapubic catheter care at the insertion site was important in preventing infections.
-She agreed the lack of suprapubic catheter care could have contributed to the resident's current UTI.
Review of the provider's undated Suprapubic Catheter Care Policy and Procedure revealed:
*Policy: To keep insertion site area clean and dry and prevent infection.
*4. Clean area around catheter well with soap and warm water.
*5. Clean catheter at insertion site.
*7. Rinse and dry well.
*8. Apply thin film of antiseptic ointment to edges of opening for suprapubic catheter as ordered.
Based on observation, interview, record review, and policy review, the provided failed to ensure the following:
*Post-fall monitoring was completed and documented in a timely manner for one of one sampled resident (26) who had fallen.
*A physician's order was followed and suprapubic catheter cleaning and care at the insertion site was completed and documented for one of one sampled resident (11).
*The use of a chair alarm was monitored and documented for one of one sampled resident (14 ) who required a chair alarm.
Findings include:
1. Observation on 12/4/23 at 3:25 p.m. of resident 26 revealed she:
*Was asleep on her bed.
-Had multiple staples on the crown of her head.
Interview on 12/5/23 at 10:00 a.m. with resident 26 revealed she:
*Turned wrong and had fallen when she was returning to her bed from the bathroom a few weeks ago.
*Was taken to the emergency room (ER) after the fall and required staples to close a cut on the top of her head that occurred as a result of that fall.
Review of resident 26's electronic medical record (EMR) and paper chart revealed:
*An 11/28/23 nurse progress note completed at 2:38 a.m. indicated the resident was found on the floor of her room after an unwitnessed fall.
-She was taken to the ER for post-fall evaluation and treatment.
*An 11/28/23 ER discharge report included the following post-fall instructions:
-Follow concussion guidelines that have been given to the patient on discharge, report back to ER/clinic for any concerning signs or symptoms as outlined in the handout.
-Signs and symptoms included mental status and vision changes.
*A nurse progress note dated 11/28/23 at 9:30 a.m. indicated the resident had returned to the facility from the ER.
*The resident's Post Fall 72-Hour Monitoring Report for the 11/28/23 fall:
-Included spaces for the following to have been documented: the resident's vital signs, orientation, skin condition, pain, range of motion/extremity strength, and eye responses.
--That documentation was expected to have been initiated upon the resident's return from the ER then should have continued at the following intervals: Every 15 minutes for the first hour after the initial assessment. Every 30 minutes for the next hour. Every hour for the following two hours then every 12 hours for the next three days.
*Resident 26's inital assessment was documented on her Post-Fall 72-Hour Monitoring Report at 7:35 p.m. on 11/28/23.
-That was nine hours after she had returned from the ER.
*Subsequent assessments were documented every 12 hours thereafter for three days.
Interview on 12/6/23 at 9:00 a.m. with interim director of nursing (DON) B regarding resident 26's post-fall assessments and documentation revealed:
*Licensed practical nurse (LPN) G was responsible for the documentation but had not initiated the Post Fall 72-Hour Monitoring Report upon resident 26's return from the ER on [DATE].
-That report should have been completed any time a rersident fall occurred.
*Completion of that report was important for any resident who had sustained a head injury.
-Her risk for a post-fall complication such as a brain bleed was high.
Review of the 10/23/23 Falls Event Checklist revealed the Post Fall 72-Hour Monitoring Report was expected to have been initiated and completed any time a resident fall occurred.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the provider failed to have an acknowledged and signed code status that was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the provider failed to have an acknowledged and signed code status that was easily accessible for three of three sampled residents (186, 32, and 33). Findings include:
1. Review of resident 186's electronic medical record (EMR) revealed:
*He was admitted on [DATE].
*There was no code status documented for the resident on the demographic section at the top of the EMR screen.
*There was no physician's order located for a code status.
Review of resident 186's care plan revealed:
*He had signed an Advanced Directive that was in his EMR.
*There was no documentation of his code status.
Review of the provider's list of resident code status located at the nurse's station revealed that resident 186 was not on that list.
Review of resident 186's paper chart revealed:
*There was no indication of his code status on the outside of the paper chart binder.
*The advanced directive/code status was not quickly accessible for staff in an emergency situation to find the resident's code status.
2. Review of resident 32's EMR revealed:
*She was admitted on [DATE].
*The code status in the profile section at the top area of her EMR screen was blank.
*There was no physician order for code status located in the EMR.
Review of resident 32's care plan revealed:
*She had signed an advanced directive that was in her chart.
*There was no documenation of her code status.
Review of the provider's list of resident's code statuses located at the nurse's station revealed her name was not on that list.
Review of resident 32's paper chart revealed:
*There was no documentation of her code status on the outside of the chart's binder.
*The advanced directive/code status form was not on the top page of her chart and in an emergency situation the chart would have to be gone through to find the resident's code status.
3. Review of resident 33's EMR revealed:
*She was admitted on [DATE].
*The code status in the profile section at the top area of her EMR screen was blank.
*There was no physician order for a code status located in her EMR.
Review of resident 33's care plan revealed:
*She had signed an advanced directive that was in her paper chart.
*There was no documentation of her code status.
Review of the provider's list of resident's code statuses located at the nurse's station revealed her name was not on that list.
Review of resident 33's paper chart revealed:
*There was no documentation of her code status on the outside of the chart's binder.
*The advanced directive/code status form was not the top page of her chart and indicated that in an emergency the chart would have to be gone through to have found the resident's code status.
Interview on 12/5/23 at 10:24 a.m. with licensed practical nurse (LPN) F regarding resident's code statuses revealed he:
*Was a contract travel nurse and had worked at the facility since 5/19/23.
*Would have looked in the residents' EMR for a code status if there had been a resident emergency.
*Agreed several resident EMRs did not have a physician's orders for their code statuses.
*Would have looked at the provider's list of resident code statuses located at the nurse's station if there was no physician's order for a resident code status in their EMR.
*Agreed the resident code status list was not up to date.
*Was unsure who was responsible for updating that list or what the process was for updating the list.
*Agreed if there was a resident emergency, he would have had to look at the resident's advanced directive form located in their chart at the nurse's station.
*Stated the resident's advance directive form was located at the front of the chart.
*Reviewed two resident charts and agreed their advanced directive forms were not located in the front of their paper charts.
-One resident chart had the advance directive form located toward the front of the chart under the condition alert tab.
-The other chart reviewed had an advance directive form located under the advanced directive tab that was located farther back in the chart.
*Agreed the location of the advance directive form in the charts was inconsistent.
*Agreed the inconsistencies in the location of documented code status for residents could have led to errors and delays for residents in an emergency situation.
Interview on 12/5/23 at 10:47 a.m. with interim director of nursing B regarding resident code status revealed:
*She had been employeed for approximately two months.
*She agreed the location for the resident's documented code status was not consistent.
*There was no process for where a resident's code status was to have been documented and located, and that could have led to inconsistencies and delays in an emergency situation.
Review of the provider's revised May 2020 Advance Directives Policy revealed:
*This policy is to provide an atmosphere of respect and caring and to ensure that each resident's ability and right to participate in medical and mental health decision making is maximized. Additionally, the purpose of this policy is to assure compliance with the Patient Self Determination Act (PSDA) in such a manner as to expand the patient, personnel, and community knowledge base regarding advanced directives and the process by which patient participation in medical decision making is carried out at Five Counties Nursing Home.
*It is the policy of Five Counties Nursing Home to respect and encourage resident self-determination. Residents will be encouraged to communicate their desires in regard to advance directives to their resident representative, to allow for guidance to health care providers following the resident's wishes should the resident become incapacitated, rendering them unable to make decisions.
-The advance directive policy had no documentation regarding the location of the resident's advance directive or code status for immediate accessibility to staff in an emergency situation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, job description review, and policy review, the provider failed to follow a proce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, job description review, and policy review, the provider failed to follow a process to thoroughly assess, implement, monitor, and revise interventions for one of one sampled resident (26) who was at nutritional risk. Findings include:
1. Observation on 12/4/23 at 12:30 p.m. of resident 26 in the dining room revealed:
*She fed herself the noon meal without observed chewing or swallowing difficulties.
*The texture of her food was the consistency of a regular diet.
Review of resident 26's electronic medical record (EMR) revealed:
*Registered dietician (RD) E's 5/25/23 initial dietary assessment indicated the resident was eating 100% of her meals, her weight was 141 lbs, and her nutritional status was normal.
-There were no additional RD assessments or progress notes completed since that initial assessment.
*Dietary manager (DM) D completed two progress notes (PN) between 5/17/23 and 12/5/23.
-Her 8/17/23 PN: The resident's weight was down 5% over the last 30 days but that was planned due to an increase in her diuretic medication. There was no documentation of what her weight was. The resident ate 100% of her meals and was able to make her needs known.
-Her 11/16/23 PN: The resident's weight was 139 lbs. This is a 10% [weight] loss that was unplanned. The resident had no trouble chewing or swallowing, continued to make her needs known, but her meal intake had declined to 76%.
*Resident 26's unrevised 5/17/23 care plan included a dietary goal to maintain weight and nutritional balance through the review date.
*Interventions included: following her diet as prescribed, monitoring signs/symptoms of dysphagia, eating in an upright position, eating slowly, and chewing thoroughly.
-There was no documentation that resident had weight loss or that any nutritional interventions had been implemented to address her weight loss.
*Her weight on 12/4/23 was 134.5 lbs.
Interview on 12/4/23 at 3:30 p.m. with DM D regarding nutritional interventions for residents with weight loss revealed:
*Caloric supplements (usually in the form of juices or other beverages) were prepared several times a day by dietary staff and provided to the nursing staff to distribute to residents with weight loss.
*The 10/25/23 Supplement List initialed by DM D was developed by her with input from the interdisciplinary team members (IDT).
-Resident 26's name was not on that supplement list.
*There was a resident Snack List that included different types of snacks beside some residents' names that were offered or provided to a resident when they had requested a snack.
-Cookie was listed beside resident 26's name.
*There was a list in the kitchen that included individual resident food likes and dislikes that was referred to by kitchen staff when preparing resident meals to encourage food/fluid intake.
-Resident 26's food likes included orange juice and hot green tea.
*DM D and RD E had not collaborated on the development or use of information on the Supplement, Snack, or food preference lists.
-DM D thought RD E was mostly happy with the interventions referred to above that she had implemented for residents with weight loss.
Interview on 12/5/23 at 10:00 a.m. with resident 26 revealed she:
*Knew she had lost weight since her admission on [DATE] but was not concerned because she doesn't want to get fat.
*Was not purposefully trying to lose weight but was more conscious of making healthier food choices.
Interview on 12/5/23 at 10:15 a.m. with cook N regarding interventions used to add caloric value to food for residents with weight loss revealed she:
*Sometimes added a fortified powder to a resident's coffee or oatmeal if she felt they needed a little something extra in terms of caloric intake.
-There was no process in place if a resident was expected to have been provided fortified food.
*Resident 26 was not receiving fortified food or fluids.
Interview on 12/5/23 at 10:45 a.m. with DM D regarding RD E's consultations revealed:
*She provided RD E with a form in preparation for her monthly consultation that listed all resident names, their room numbers, and their current weight.
-If she made comments in the concern column next to a specific resident name that prompted RD E to review the resident's nutritional status.
*DM D relied on her judgment and input from the IDT to identify resident concerns.
-RD E was expected to respond to the concerns referred to above in the recommendation column of that form then complete a full progress note in the resident's EMR regarding her findings.
*DM D had not retained a record of the original monthly RD reports.
*Review of the November 2023 dietician consultation form revealed:
-DM D had added no concerns for resident 26 on the November 2023 form even though she had known the resident had weight loss.
Continued interview with DM D regarding resident 26's weight loss revealed:
*Either her or RD E's PNs should have included information about if:
-The resident had been interviewed regarding her intake goals or food preferences.
-The resident had been observed during mealtimes for environmental or functional factors that impacted her weight loss.
-Staff had been interviewed to gain mealtime or dietary-related information regarding her weight loss.
-Specific dietary interventions had been implemented and whether or not they had or had not been effective in relationship to her weight loss.
-The resident had new diagnoses or medication changes that may have affected her weight.
-Her weight record, a review of nurse and physician progress notes, laboratory values had been evaluated.
-The resident's medical provider had been made aware of the unplanned weight loss.
*The resident's weight loss was discussed during monthly quality assurance and performance improvement (QAPI) meetings.
-She was responsible for reporting information related to residents who had lost 10% of their body weight and residents that had lost 5% of their body weight in the previous 30 days.
*Review of DM D's weight loss data reported to QAPI revealed:
-Between June 2023 through August 2023 resident 26 had not been discussed.
-It was reported during the September 2023 the resident 26 had a 10% weight loss: Resident 26 had a diuretic [medication] increase. She is eating meals over 76% and is able to inform staff of her wants or needs. Plan: We will continue to monitor and encourage.
-It was reported during the October 2023 the resident continued to be monitored for having lost 10% of her body weight. Plan: Working with nursing on getting special snacks out to these residents daily and charted.
*DM D agreed the data referred to above related to resident 26's weight loss had not:
-Identified contributing factors to her weight loss, possible causes for her weight loss, or changes that had been made to address the possible causes for her weight loss.
-Measured the success or failure of any changes that had been made.
*RD E had not attended QAPI meetings and DM D had not discussed the quality of care measure referred to above that she was following and reporting to the QA team related to resident weight loss.
*DM D thought her workload limited her ability to manage the overall operation of the kitchen which she felt was her primary work responsibility.
*Some of her responsibilities seemed more appropriate for RD E to have carried out based on her clinical experience and educational background.
-DM D had no RD job description to refer to for the RD's job duties.
Interview on 12/6/23 at 11:15 a.m. with administrator A and interim DON B revealed:
*Administrator A had been in her current position for a few weeks and interim DON B had been in her current position for a few months.
*They had known there were concerns regarding the process for managing resident weight loss because it was being discussed during monthly QAPI meetings.
*They were not aware that there was no job description for RD E but agreed without that job description:
-There had been a lack of collaboration between DM D and RD E regarding dietary-related expectations and services.
-DM D assumed dietary-related responsibilities that were not within the scope of practice for a DM to have carried out.
-RD E had not been accountable for ensuring the recognition, evaluation, monitoring, and documentation expectations for residents at nutritional risk had been followed.
*RD E had retired.
-They agreed her retirement created an opportunity to establish written job expectations and accountability expectations for the next RD that was hired.
Review of the 1/11/23 Maintaining Nutrition Status policy revealed: It is the intent of Five Counties Nursing Home to prevent the unplanned weight loss, if unavoidable, in our residents by providing assessments for nutrition and hydration and applying interventions appropriate for individual resident needs.
Review of the 10/30/15 Dietary Manager job description revealed duties included:
*Managing food operations of the facility.
*Assures proper documentation of weights, intakes and any other dietary resident issues.
*Utilizes the services of a clinical dietician to assist in management of the dietary department.
*Assures that the dietary department is in compliance with all state, federal and local regulations.
*Conducts inservicing for the dietary personnel, facility personnel and monthly scheduling.
Nov 2022
1 deficiency
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · 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 risk versus benefits education f...
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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 risk versus benefits education for resident and family or representative, informed consent from resident and family or representative, and physician acknowledgement for side rails had been completed and documented for 10 of 10 sampled residents (4, 5, 21, 24, 25, 27, 28, 29, 33, and 37) prior to the implementation of side rails. Findings include:
1. Observation and interview on 10/31/22 at 2:37 p.m. with resident 4 revealed:
*There had been bilateral side rails attached to the upper portion of the bed in the up position.
*Her 8/29/22 brief interview of mental status (BIMS) score was a 13, meaning she was cognitively intact.
*She seldom used the side rails.
*They had been attached to the bed when she was admitted on [DATE].
Review of resident 4's medical record revealed her care plan included she used an assist bar [side rail] for turning and repositioning in bed.
2. Observation and interview on 11/1/22 at 9:27 a.m. with resident 37 and her daughter revealed:
*Her daughter stated resident 37 had a brain tumor removed and did not remember things.
*There had been bilateral side rails attached to the upper portion of the bed in the up position.
*She used the side rails to help position herself when in bed and to get in and out of bed.
*Her daughter did not remember receiving or signing a risk education versus benefit education and informed consent.
Review of resident 37's medical record revealed:
*Her 8/29/22 BIMS was 8, meaning she had moderate cognitive impairment.
*She had been admitted on [DATE].
*Her care plan included she used an assist bar for turning and repositioning in bed.
3. Observation 11/3/22 from 8:27 a.m. through 8:44 a.m. revealed residents' 5, 21, 24, 25, 27, 28, 29, and 33's rooms there had been bilateral side rails attached, to each of their beds, on the upper portion of the bed in the up position.
4. Interview on 11/2/22 at 11:45 a.m. with director of nursing B and social service designee P revealed there had not been risk education versus benefit education and informed consent completed with any residents who had side rails installed on their beds.
5. Interview on 11/2/22 at 4:45 p.m. with administrator A regarding the side rails revealed:
*He had been aware that risk education versus benefit education and informed consent needed to be completed with all residents who had side rails installed on their beds.
*He was not aware they had not been done.
6. Review of the provider's November 2018 assist bar [side rail] policy revealed:
*Policy statement: [Provider} will not routinely use half rails or transfer bars unless indicated by physician or therapist. Some beds are equipped with assist bars that residents can use for bed mobility.
*The policy had not included that risk education versus benefit education and informed consent were required.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Special Focus Facility, 2 harm violation(s), $31,850 in fines. Review inspection reports carefully.
- • 34 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $31,850 in fines. Higher than 94% of South Dakota facilities, suggesting repeated compliance issues.
- • Grade F (5/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Five Counties Nursing Home's CMS Rating?
CMS assigns Five Counties Nursing Home 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 Five Counties Nursing Home Staffed?
CMS rates Five Counties Nursing Home's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the South Dakota average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Five Counties Nursing Home?
State health inspectors documented 34 deficiencies at Five Counties Nursing Home during 2022 to 2025. These included: 2 that caused actual resident harm and 32 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Five Counties Nursing Home?
Five Counties Nursing Home 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 42 certified beds and approximately 34 residents (about 81% occupancy), it is a smaller facility located in LEMMON, South Dakota.
How Does Five Counties Nursing Home Compare to Other South Dakota Nursing Homes?
Compared to the 100 nursing homes in South Dakota, Five Counties Nursing Home's overall rating (1 stars) is below the state average of 2.7, staff turnover (48%) 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 Five Counties Nursing Home?
Based on this facility's data, families visiting should ask: "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?"
Is Five Counties Nursing Home Safe?
Based on CMS inspection data, Five Counties Nursing Home has documented safety concerns. The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). 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 Five Counties Nursing Home Stick Around?
Five Counties Nursing Home has a staff turnover rate of 48%, 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 Five Counties Nursing Home Ever Fined?
Five Counties Nursing Home has been fined $31,850 across 1 penalty action. This is below the South Dakota average of $33,397. 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 Five Counties Nursing Home on Any Federal Watch List?
Five Counties Nursing Home is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.