Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dells Nursing And Rehab Center Inc during CMS and state inspections, most recent first.
Resident bedtime choice not honored: A resident with moderately impaired cognition and a care plan noting he went to bed when sleepy reported that staff would not let him go to bed at 6:00 p.m. and made him wait until 7:00 p.m. because supper was still in progress. CNA interviews confirmed they would not always accommodate an early bedtime request, while the RN, SSD, and DON acknowledged residents had the right to decide when they went to bed.
Infection prevention practices were not followed for clean equipment, oxygen tubing care, and EBP PPE use. Lift slings were observed touching the floor in the clean linen room, a resident’s oxygen tubing was documented as replaced despite being dated earlier than the facility’s expected monthly schedule, and a CNA provided shower care to a resident on EBP without wearing a gown or gloves.
A resident with diabetes and orthostatic hypotension did not receive blood pressure medications according to physician-ordered parameters. Midodrine and Fludrocortisone were both administered outside of the specified blood pressure ranges, and low blood pressures were not promptly rechecked. CMAs involved were unaware of the facility's blood pressure policy, and required notifications and documentation were not completed as per facility protocols.
The facility did not use current Medicare notification forms or fully complete required information when informing three residents and their representatives about the end of Medicare Part A skilled services. Outdated NOMNC and SNF ABN forms were used, missing key details such as the type of services ending and QIO contact information. Two of the affected residents had severe cognitive impairment, and one had moderate impairment. The social services designee was unaware of the updated requirements and did not document all necessary information during phone notifications.
Surveyors found that staff did not consistently use PPE during high-contact care for residents on enhanced barrier precautions, and urinary catheter care practices were not in line with facility policy, with reused and improperly stored catheter bags and unlabeled supplies. Several CNAs were unfamiliar with updated infection control policies, and documentation of staff education was incomplete. The facility also lacked comprehensive written policies for infection surveillance, communicable disease reporting, and isolation precautions, and expired or unlabeled medical supplies were found in storage areas.
A facility failed to implement and monitor care plans for pressure ulcer prevention, leading to the development of ulcers in three residents. One resident developed a heel ulcer due to delayed use of Prevalon boots, while another had a stage II ulcer without proper cushion support. A third resident had open areas on his buttocks without adequate pressure reduction interventions. The facility lacked documentation and staff training on pressure ulcer care.
The facility inaccurately submitted PBJ data for a federal fiscal quarter, showing no licensed nursing coverage on certain days, despite records indicating otherwise. The administrator, responsible for PBJ submission, was unaware of the discrepancies and speculated manual entry errors might be the cause, though some missing coverage days were not staffed by agency staff.
The facility failed to implement enhanced barrier precautions (EBP) and proper infection control practices. Observations showed a lack of PPE, improper hand hygiene, and expired products in resident care areas. Staff interviews revealed insufficient training and awareness of EBP protocols and infection control measures.
A LTC facility failed to update care plans for several residents, leading to deficiencies in care. Residents experienced falls, pressure ulcers, UTIs, and elopement risks without appropriate updates to their care plans. The facility's care planning process did not consistently reflect residents' changing needs and conditions.
The facility failed to secure chemicals properly, with observations showing unlocked cabinets and rooms containing various chemicals, some outdated or improperly labeled. Staff interviews revealed a lack of awareness and adherence to chemical storage policies, despite clear instructions and expectations for secure storage.
A facility failed to prevent significant medication errors, including a resident receiving another's medications, a non-diabetic resident given insulin, and a resident administered a discontinued medication. These errors highlight lapses in medication verification and staff training.
A resident with severe cognitive impairment experienced significant weight loss due to inadequate monitoring and documentation of meal consumption. Despite requiring assistance with eating, the resident was not consistently encouraged or assisted during meals, and meal intake was poorly documented. The care plan did not address the resident's weight loss, and there was a lack of hydration documentation, contributing to the deficiency.
The facility failed to implement an effective antibiotic stewardship program, leading to repeated antibiotic prescriptions for a resident with chronic UTIs without proper documentation or decision-making tools. Staff inconsistencies in obtaining and documenting orders for urine tests were noted, and the infection preventionist's tracking was limited to a spreadsheet. The facility's infection control policy was not effectively implemented, resulting in multiple residents being prescribed antibiotics without clear lab-confirmed infections.
A controlled medication, morphine sulfate, was not properly secured or accounted for in a facility. RN D did not perform the required narcotic count with LPN R at the end of her shift, leading to the discovery of missing medication the following day. Nurse manager C and the pharmacy investigated the incident, revealing a failure to adhere to the facility's Narcotic Count Policy.
The facility failed to report missing controlled medication, specifically morphine sulfate, to the SD DOH in a timely manner. The nurse manager and administrator were unaware of the reporting timeline and did not follow the facility's policy for reporting potential diversion of controlled substances. The incident was discovered on November 24, but the FRI was not submitted until December 4, highlighting a deficiency in timely reporting and adherence to protocols.
A resident with moderate cognitive impairment eloped from the facility after a door alarm was turned off and not reactivated. The resident was found outside, having left the dining room unnoticed. The incident revealed a lapse in safety protocols related to door alarm management.
A resident's bruise of unknown origin was not reported or investigated according to the facility's policy. The LPN failed to document the bruise, notify the family and physician, or report it to the charge nurse or DON. The DON and administrator acknowledged the lapse in procedure, which was not monitored recently, leading to the deficiency.
The facility failed to maintain the dishwasher, resulting in food scum and limescale buildup. Observations showed the dishwasher had not been cleaned or delimed regularly, with staff unaware of the cleaning schedule. The last recorded deliming was two months prior, contrary to the facility's policy requiring regular maintenance.
A facility failed to report a resident's abnormal blood sugar levels to the doctor as required by the physician's orders. Additionally, a prescription ointment was improperly stored at a resident's bedside without a physician's order or assessment, contrary to the facility's policy. Staff interviews confirmed these deficiencies.
The facility failed to serve adequate portion sizes during a lunch service, with Cook H using incorrect scoop sizes for taco bake, resulting in servings that were less than the menu requirements. Cook H was unaware of the correct portion sizes, and the acting dietary manager was not informed of the issue.
Resident bedtime choice not honored
Penalty
Summary
The facility failed to ensure a resident’s bedtime choices were followed for one sampled resident who stated he sometimes felt tired and wanted to go to bed at 6:00 p.m., but staff told him he had to wait until 7:00 p.m. because some residents were still eating supper. During observation, the resident was in his room sitting in a recliner watching television and reported that this delay occurred on days when he wanted to go to bed early. Interviews with nursing staff showed the practice of delaying bedtime requests was routine. A CNA stated she would not accommodate a 6:00 p.m. bedtime request because she felt it was too early, and another CNA said she would ask the charge nurse, who would normally have the resident stay awake until at least 7:00 p.m. The RN, SSD, and DON acknowledged that some residents requested to go to bed early, that residents had the right to decide when they went to bed, and that staff were not always sure they would accommodate those requests. The resident’s EMR showed a BIMS score of 9, indicating moderately impaired cognition, and his care plan stated he liked to wake up around 7:00 a.m. and go to bed around 8:00 p.m. or whenever he was sleepy.
Infection Prevention and Control Failures
Penalty
Summary
The provider failed to ensure standard infection prevention practices were followed for clean resident-use equipment, oxygen tubing replacement, and PPE use during care for a resident on enhanced barrier precautions (EBP). In the clean linen room, more than five lift slings were observed touching the floor. The infection preventionist/RN stated she was not aware the slings were touching the floor and acknowledged the floor was not considered a clean surface; she then removed the slings so they could be laundered. For resident 35, the oxygen concentrator’s humidification container and oxygen tubing were observed dated 11/3/25, while the resident’s TAR documented the oxygen tubing replacement as completed on 11/24/25. The infection preventionist stated oxygen tubing was expected to be replaced every four weeks by the night shift nurse, and the DON stated the night shift nurse would document the task as completed in the TAR. For resident 15, CNA D was observed providing a shower without wearing a gown or gloves despite knowing the resident was on EBP. The CNA acknowledged she was not wearing PPE when assisting the resident to undress and at the start of the shower, and stated she put on a gown and gloves only after realizing she had forgotten them.
Failure to Administer Blood Pressure Medications per Physician Orders
Penalty
Summary
The provider failed to ensure that blood pressure medications were administered according to physician orders for a resident with diagnoses of type 2 diabetes, orthostatic hypotension, and weakness. Upon admission, the resident had specific orders for Midodrine and Fludrocortisone, both with hold parameters based on systolic blood pressure (SBP) readings. Review of the Medication Administration Record (MAR) revealed that Midodrine was administered six times when the resident's SBP was above the ordered threshold, and was not given five times when the SBP was low and the medication should have been administered. Fludrocortisone was also administered twice when the SBP was above the hold parameter. In addition, low blood pressures were not rechecked until the following day when Midodrine was held, contrary to expectations. Interviews with the Director of Nursing (DON) and Certified Medication Aides (CMAs) confirmed that the staff responsible for administering the medications did not consistently follow the blood pressure hold parameters. The DON acknowledged that the facility's policy required blood pressure to be checked prior to administration and that the physician should be notified if readings were out of parameters. The CMAs involved were not aware they had administered medications outside of the prescribed parameters and were unfamiliar with the facility's Blood Pressure Parameter Policy and notification requirements. Review of job descriptions and facility policies indicated that CMAs and RNs were responsible for observing and reporting symptoms, taking and recording vital signs, and notifying the charge nurse of medication errors. The facility's policies also required that medication errors be reported, the physician and DON notified, and the resident monitored for 24 hours following an error. Despite these policies, the required procedures were not followed, resulting in multiple medication administration errors for the resident.
Failure to Provide Proper and Updated Medicare Coverage Notices
Penalty
Summary
The provider failed to ensure that proper Medicare notices were completed fully and in the required format for three sampled residents prior to their discharge from Medicare Part A skilled services. Specifically, the facility used outdated versions of the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms, despite updated forms being mandated for use as of specific dates. The NOMNC forms did not specify the type of services ending, such as skilled nursing, and lacked required contact information for the Quality Improvement Organization (QIO), including the name and toll-free number. Additionally, the forms did not include all information required when notice was delivered by phone to a resident's representative, such as the last day of covered services, the date liability would begin, and details about the appeal process. The sampled residents included two who remained in the facility after their Medicare Part A coverage ended and one who was discharged home. Among these, two residents had severe cognitive impairment and one had moderate cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. The facility's social services designee (SSD) completed the forms and contacted the residents' representatives by phone, but failed to document all required information on the forms and did not mail annotated copies to the representatives as required. During an interview, the SSD acknowledged being unaware that the forms used were outdated and that new forms were required. The SSD also agreed that the forms were not fully completed according to instructions, including missing information about the type of services ending and the QIO contact details. The SSD was not aware of the specific documentation requirements for telephone notification to representatives, resulting in incomplete records for the residents affected.
Deficient Infection Control Practices and Incomplete Policy Implementation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility’s infection prevention and control practices, particularly regarding the use of enhanced barrier precautions (EBP) and urinary catheter care. Certified nursing assistants (CNAs) were observed failing to consistently wear appropriate personal protective equipment (PPE) when providing care to residents on EBP, such as not donning gowns during high-contact activities like transfers. In one instance, a CNA transferred a resident with open wounds without wearing a gown, despite EBP signage and CDC guidance posted in the facility. Additionally, staff did not always perform hand hygiene after removing PPE or before assisting residents with personal items. The facility’s practices for urinary catheter care and storage were inconsistent with policy and infection control standards. Catheter collection bags were reused, stored in plastic trash bags tied to towel racks, and not always labeled or dated. Staff described and demonstrated cleaning procedures that varied from the written policy, including the use of an incorrect vinegar-to-water ratio for cleaning solutions and leaving cleaning solution in bags for extended periods. Supplies such as normal saline and syringes were found opened, unlabeled, and not properly stored or disposed of in resident rooms and supply areas. Several CNAs were unfamiliar with the revised catheter care policy, and documentation of staff education on new policies was incomplete. The facility’s infection prevention and control program lacked comprehensive written policies and procedures in several required areas. There was no documented system for infection surveillance, reporting communicable diseases, determining the duration and restrictiveness of isolation precautions, or prohibiting staff with communicable diseases from resident contact. The policies provided did not address these elements, and staff interviews confirmed the absence of written guidance, relying instead on verbal instructions or external resources. Expired and unlabeled medical supplies were also found in storage areas, further indicating lapses in infection control practices.
Failure to Implement and Monitor Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and monitor care planned approaches for a resident identified on admission as having potential for pressure ulcer development, leading to the development of a heel pressure ulcer. The resident was admitted for strengthening due to a urinary tract infection and had a black spot on her left heel that was not present upon admission. Despite standing orders for Prevalon boots for pressure ulcer prevention, the resident did not start using them until after the sore developed. The care plan was not revised once the skin alteration was identified, and there was a lack of documentation regarding the skin alteration on admission. Two other residents acquired pressure ulcers after admission due to inadequate implementation and monitoring of care plan approaches. One resident had a stage II pressure ulcer on her left hip, but the care plan was not updated to include the use of pressure-reduction devices like the ROHO cushion. The cushion was not inflated, and there was no cushion in the resident's recliner. The facility's staff were not adequately trained on the use and maintenance of the ROHO cushions, and the care plan lacked documentation of the pressure ulcer's progression to healing. Another resident reported pain in his buttocks, and upon examination, open areas were found. The resident's care plan did not include pressure reduction interventions, and there was no pressure reduction cushion in his recliner. The facility's policy required weekly documentation of wounds, but there was no documentation of the size, number of open areas, or specific locations of the pressure ulcer. The facility failed to ensure that staff were aware of and implemented the necessary interventions for pressure ulcer prevention and care.
Inaccurate PBJ Data Submission for Nursing Coverage
Penalty
Summary
The provider failed to accurately submit Payroll Based Journal (PBJ) data for one federal fiscal quarter, specifically Quarter 4, 2024. The PBJ records submitted to the Centers for Medicare and Medicaid Services (CMS) indicated that there was no licensed nursing coverage for 24 hours on specific dates in September 2024. However, a review of the provider's employee timecards, staffing schedules, and residents' electronic medical records (EMR) showed that there was indeed licensed nursing coverage during those times. An interview with the administrator and nurse manager revealed that the nurse manager was responsible for creating the nursing schedule but did not participate in the PBJ submission process. The administrator, who submitted the records, relied on an electronic payroll system to automatically obtain information from individual staff timecards and manually entered agency staff hours. The administrator was unaware of the discrepancies in the PBJ reports and did not know how to access them. She speculated that the errors might have been due to manual entry of agency staff hours, but some missing coverage days were not staffed by agency staff, leaving the cause of the incorrect reporting unresolved.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to accurately identify and implement enhanced barrier precautions (EBP) for residents with care concerns requiring personal protective equipment (PPE). Observations revealed that there was no PPE available in the hallway or residents' rooms, and residents with wounds or indwelling medical devices were not placed on EBP. For instance, a resident with a wound on her right lower extremity was observed without any PPE or EBP signage in her room, despite having a dressing order for her wound. Interviews with staff indicated a lack of understanding and implementation of EBP protocols, with some staff unaware of the criteria for placing residents on EBP. The facility also failed to utilize appropriate hand hygiene and gloves during resident care. A certified nursing assistant (CNA) was observed performing various tasks, such as removing hair rollers, taking vital signs, and assisting with showers, without proper hand hygiene or glove changes. Shared resident care items, such as razors and lotions, were not disinfected between uses, and expired products were found in multiple areas, including the beauty shop and hopper rooms. Staff interviews revealed a lack of training and awareness regarding the cleaning and disinfection of shared items and the importance of hand hygiene. Additionally, the facility did not appropriately maintain and dispose of resident care items in hopper rooms, the shower room, and the beauty shop. Observations showed expired products, improperly stored items, and a lack of alcohol-based hand sanitizers in these areas. Staff were observed disposing of trash without washing their hands, and there was no clear policy for checking and removing expired products. Interviews with the director of nursing and other staff members highlighted a lack of oversight and responsibility for ensuring proper infection control practices and maintaining a clean and safe environment for residents.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that resident care plans were updated to reflect the current needs of several residents, leading to deficiencies in care. Resident 34 experienced multiple falls, including one that resulted in a laceration requiring emergency room treatment. Despite being identified as at risk for falls, her care plan was not updated with new interventions following these incidents. Similarly, residents 4 and 9, who also experienced multiple falls, did not have their care plans updated with fall prevention interventions, despite the facility's policy requiring such updates. Resident 10, who had a history of urinary tract infections (UTIs), did not have her care plan updated to reflect ongoing issues with UTIs, despite multiple antibiotic treatments. The care plan had not been revised since March of the previous year, failing to address her recurrent infections. Additionally, resident 29, who attempted to leave the facility without staff knowledge, was identified as at risk for elopement, but her care plan did not reflect this risk or the interventions put in place following the incident. Residents 7 and 11 also had deficiencies in their care plans. Resident 7, who developed a facility-acquired pressure ulcer, did not have her care plan updated to include the use of pressure-reduction devices. Resident 11, who was prescribed psychotropic medications, did not have her care plan updated to monitor for adverse effects or include non-pharmacological interventions for her hallucinations and anxiety. These oversights indicate a systemic issue with the facility's care planning process, as care plans were not consistently updated to reflect residents' changing needs and conditions.
Inadequate Chemical Storage and Security
Penalty
Summary
The provider failed to ensure that chemicals were stored securely and in accordance with their written instructions, leading to potential accident hazards. Observations revealed that chemicals were stored under sinks in four different rooms, including the Garden Terrace hopper room, Happy Trails hopper room, beauty shop, and shower room. In each instance, the cabinets or rooms were not locked, and various chemicals, some with broken tops or outdated labels, were accessible. Signs were present indicating that chemicals should be kept in locked cupboards, but these instructions were not followed. Interviews with staff, including CNAs, housekeeping, and the DON, confirmed that there was an expectation for chemicals to be stored in locked areas and not under sinks. However, there was a lack of awareness and adherence to these expectations. The DON and nurse manager were unaware of the unlocked cabinets and the presence of chemicals under sinks, despite previous instructions that products should not be stored there. The facility's chemical safety policy emphasized the safe use and storage of chemicals, but it was primarily focused on dietary staff and food contamination, indicating a possible gap in comprehensive chemical storage practices across the facility.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving incorrect medication administration. Resident 33 was mistakenly given another resident's medications, including Tylenol, Olanzapine, Celecoxib, and Tamsulosin, by a certified medication aide. Similarly, Resident 34 received Carbidopa/Levodopa, a medication not ordered for them, leading to the involvement of poison control to monitor for adverse reactions. Resident 11, who was not diabetic, was mistakenly administered 7 units of NovoLog insulin after being confused with another resident. This error was documented, and the resident's primary doctor and daughter were notified. However, there were no further blood glucose checks recorded in the resident's electronic medical record, and the nurse manager was unsure if any education or review of the error had been completed. Resident 29 received Lorazepam, a medication that had been discontinued, due to a failure to verify the medication in the electronic medication administration record before administration. The medication was not removed from the narcotic drawer, leading to the error. The facility's medication error policy outlines steps to prevent, identify, report, and address such errors, but these were not effectively implemented in these cases.
Failure to Monitor and Document Resident's Nutritional Intake
Penalty
Summary
The provider failed to ensure adequate monitoring and documentation of a resident's nutritional intake, leading to consistent weight loss. During a lunch meal observation, Resident 24, who has severe cognitive impairment and requires assistance with eating, was not adequately encouraged or assisted to consume her meal. The resident consumed only a small portion of her meal, and no documentation of her consumption was made in the electronic medical record (EMR). Interviews with staff revealed a lack of awareness regarding the resident's meal consumption and weight loss, as well as issues with obtaining accurate weights and documenting meal intake. The resident's care plan included multiple focus areas related to nutrition and hydration, yet there was no update addressing her significant weight loss of over 10% in the past three months. The Registered Dietician Licensed Nutritionist noted the weight loss and suggested considering an appetite stimulant and encouraging meal intake. However, meal documentation was incomplete, with many meals lacking records of consumption, particularly evening meals. Additionally, there was no hydration documentation in the EMR, and a task to record supplemental fluids was only added after the observation date. This lack of documentation and monitoring contributed to the deficiency in maintaining the resident's health through adequate nutrition.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adequately implement and monitor an effective antibiotic stewardship program, as evidenced by multiple deficiencies in the management of urinary tract infections (UTIs) and antibiotic use. Resident 10, who had a history of chronic kidney disease, type two diabetes mellitus, and recurrent UTIs, was observed to have been prescribed antibiotics multiple times over several months without clear documentation or consistent use of decision-making tools like the SBAR form. The infection preventionist acknowledged the lack of documentation and the absence of a structured process for determining the necessity of urine dips or urinalysis, which contributed to the repeated antibiotic prescriptions. Interviews with staff, including the infection preventionist and registered nurses, revealed inconsistencies in the process of obtaining and documenting orders for urine dips and urinalysis. Staff were not consistently documenting the reasons for performing urine dips or obtaining urinalysis, and there was no standardized form in use to guide these decisions. The infection preventionist admitted that the facility's tracking of infections and antibiotic use was limited to a spreadsheet discussed at QAPI meetings, and there was no comprehensive system in place to ensure appropriate antibiotic use. The facility's infection control and prevention policy outlined the responsibilities of the infection preventionist, including tracking and reporting antibiotic use and infections. However, the policy was not effectively implemented, as evidenced by the lack of systemic data collection and documentation. The report highlighted that from August to December, multiple residents were prescribed antibiotics more than once, and there was no clear evidence of lab-confirmed infections for all cases. This deficiency in antibiotic stewardship could potentially lead to adverse events associated with antibiotic use, although the report did not explicitly state such consequences.
Failure to Secure and Account for Controlled Medication
Penalty
Summary
The deficiency involved the failure to secure and account for a controlled medication, specifically morphine sulfate, for a resident. On the morning of November 23, 2024, RN D counted the resident's narcotics at the start of her shift and found no discrepancies. However, at the end of her shift, RN D did not perform the required narcotic count with LPN R, who initially refused to conduct the count until RN D insisted. The following day, RN D was called back to the facility to assist in locating the missing morphine sulfate, which was not accounted for. LPN R had already left the facility without resolving the issue. Nurse manager C was informed of the missing six milliliters of morphine sulfate and worked with the pharmacy to investigate the incident. Initially, the missing medication was not considered theft until the pharmacy clarified it as such. The controlled drug receipt/record/disposition form indicated that the last dose of morphine sulfate was administered on November 16, 2024, with six milliliters remaining. The facility's undated Narcotic Count Policy required narcotics to be counted by licensed nursing personnel at the beginning and end of each shift, which was not adhered to in this instance.
Failure to Timely Report Missing Controlled Medication
Penalty
Summary
The provider failed to report the missing controlled medication, specifically six milliliters of morphine sulfate, to the South Dakota Department of Health (SD DOH) in a timely manner. The incident was initially discovered on November 24, 2024, but the Facility Reported Incident (FRI) was not submitted until December 4, 2024. Interviews with the nurse manager and the administrator revealed a lack of awareness regarding the timeline requirements for reporting such incidents to the SD DOH. The nurse manager admitted to not following the facility's policy for reporting potential diversion of controlled substances and only began the paperwork for drug diversion on November 25, 2024, after being informed by the pharmacy that it was a misappropriation of a personal item. The facility's policy on Reporting and Investigating Diversion of Controlled Substances requires that investigations be completed within 48 hours of discovering an incident, with the severity of the theft or loss evaluated for reporting purposes. However, both the nurse manager and the administrator acknowledged that they did not adhere to this policy. The administrator also confirmed the failure to follow the policy for reporting potential diversion of controlled substances. The report highlights the deficiency in timely reporting and adherence to established protocols for handling controlled substances within the facility.
Resident Elopement Due to Inactive Door Alarm
Penalty
Summary
The deficiency involved a resident identified at risk for elopement who managed to leave the facility without staff knowledge. The incident occurred when a certified nursing assistant (CNA) noticed that a fire exit door in the living room was slightly open, and the alarm did not sound. The resident was found standing on the sidewalk by the door, having last been seen eating lunch in the dining room. The resident stated she was going to get hot chocolate, indicating she had left the facility without staff awareness. The failure to ensure the door alarm was reactivated after being turned off led to the resident's elopement. The door alarm system was checked immediately after the incident and was found to be turned off. This oversight in reactivating the alarm system allowed the resident to exit the building unnoticed. The resident was wearing a Tile tracking device and a watch capable of tracking her location, but these measures did not prevent the elopement. The resident involved had a Brief Interview for Mental Status (BIMS) assessment score of 10, indicating moderate cognitive impairment. At the time of the incident, the resident was wearing tracking devices, and her vital signs were within normal limits with no injuries noted. The incident highlighted a lapse in the facility's safety protocols, specifically regarding the management and monitoring of door alarms, which are crucial for preventing elopement in residents at risk.
Failure to Report and Investigate Bruise of Unknown Origin
Penalty
Summary
The provider failed to report and investigate a bruise of unknown origin on a resident's forehead, which was observed on 8/06/24. The bruise was not reported to the nurse manager or the director of nursing (DON) for further investigation. Interviews revealed that the certified nursing assistant (CNA) and licensed practical nurse (LPN) involved did not know how or when the bruise occurred. The LPN had spoken to the resident's daughter, who was unaware of the bruise, and failed to document the conversation or notify the family and physician promptly. The LPN also did not report the bruise to the charge nurse or DON, nor did she document it on the medication administration record (MAR) for daily monitoring. The director of nursing (DON) and the administrator acknowledged that the bruise should have been investigated and reported according to the facility's bruise policy. The policy required that bruises be documented, monitored, and reported to the family and physician. However, the bruise was not documented in the resident's electronic medical record, and the family was not notified. The administrator admitted that the process for reporting bruises was broken and had not been monitored recently, leading to a lapse in following the established procedures.
Dishwasher Maintenance Deficiency
Penalty
Summary
The provider failed to ensure that the dishwasher in the kitchen was adequately cleaned and delimed on a regular basis, leading to a buildup of food scum and limescale. During an initial kitchen observation, surveyors noted that the dishwasher, which was in use for cleaning breakfast dishes, had a line of limescale buildup on the outside of the door, food scum on the outside borders and inside seams of the doors, and limescale on the wash arms and piping inside the machine. Interviews with kitchen staff revealed a lack of knowledge regarding the cleaning schedule, with dietary aide J having never cleaned or delimed the dishwasher and cook I not having been tasked with this responsibility for a long time. The night shift was identified as responsible for these tasks, but there was no evidence of regular completion. Further investigation revealed that the administrator believed the dishwasher was supposed to be delimed weekly, with instructions and a deliming schedule posted on the wall. However, the last recorded deliming was approximately two months prior. The facility's dishwashing policy emphasized the importance of cleaning and sanitizing food preparation equipment to prevent disease, with the dietary manager responsible for monitoring task completion and record accuracy. The failure to adhere to this policy and maintain the dishwasher's cleanliness contributed to the observed deficiency.
Failure to Report Abnormal Blood Sugars and Improper Medication Storage
Penalty
Summary
The provider failed to report abnormal blood sugar levels for a resident as per the physician's orders. The resident had a doctor's order to check blood sugar four times daily and report if levels were below 60 or above 500. On two occasions, the resident's blood sugar levels were recorded as 542 and 517, but there was no documentation that the doctor was notified. Interviews with staff, including an LPN and a nurse manager, confirmed that the high blood sugars were not reported, despite a new policy in place to ensure such parameters are monitored and reported. The administrator was unaware of the failure to report these abnormal results. Additionally, the provider did not adhere to their policy regarding the storage of prescription medications. A resident had a prescription ointment on her bedside table without a physician's order for bedside storage. The resident, who had severe cognitive impairment, was unable to use the ointment independently. Interviews with staff, including an LPN and the DON, revealed that the ointment was intended for staff use during care and should have been stored in the medication room. The facility's policy requires a written order and assessment for bedside medication storage, which was not followed in this case.
Inadequate Portion Sizes Served During Lunch
Penalty
Summary
The provider failed to ensure that adequate portions were served according to the menu during a lunch service, which had the potential to affect all residents receiving the main menu in the facility. The menu for lunch on the specified date included one cup of taco bake and a 2/3 cup portion for the pureed version. However, during the observation of the lunch service, it was noted that Cook H used a 1/2 cup scoop for both the regular and pureed taco bake, resulting in serving sizes that were 50% and 33.33% less than the menu requirements, respectively. Interviews with the kitchen staff revealed that Cook H, who had been working at the facility for about three weeks, was not aware of the correct serving sizes and had been trained to use a 1/2 cup scoop for every recipe. Neither Cook H nor Cook I were aware of the correct portion sizes as listed on the posted menu. The acting dietary manager, Administrator A, was also unaware of the incorrect portion sizes being served, as she had recently taken over the role following the departure of the previous dietary manager.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dell Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palisade Healthcare Center | 13.4 mi | ★★★★★ | 5 | 1 |
| Flandreau Santee Sioux Tribe Care Center | 15.3 mi | ★★★★★ | 1 | 0 |
| Riverview Healthcare Center | 16.2 mi | ★★★★★ | 11 | 1 |
| Dow Rummel Village | 18.9 mi | ★★★★★ | 6 | 0 |
| Bethany Home - Brandon | 19 mi | ★★★★★ | 15 | 0 |
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