Citations in South Dakota
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in South Dakota.
Statistics for South Dakota (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in South Dakota
- The Dietary Manager educated all dietary staff on proper sink usage, water temperatures, sanitizer temperatures, and the importance of correct documentation and corrective actions when temperatures are outside requirements. ServSafe certification was pursued for key staff members, and new logs were implemented to ensure compliance with sanitation standards (L - F0812 - SD) .
- All expired test strips were removed, and new, non-expired strips were placed for use. Disposable dining ware was used temporarily until the dishwasher was functioning correctly. Staff received education on procedures for a non-working dishwasher and the importance of using non-expired test strips. Monitoring systems were established to track the expiration dates of test strips and ensure ongoing compliance (J - F0812 - SD) .
- Dietary staff were instructed to use paper plates and to wash all non-disposable items in the three-compartment sink until the dishwasher was repaired. A booster water heater was arranged to be installed to achieve the required dishwasher temperatures. New policies and temperature charts were implemented, and staff received mandatory education on the updated procedures (J - F0812 - SD) .
Failure to Maintain Proper Water Temperatures in Kitchen
Penalty
Summary
The provider failed to maintain the required water temperatures in the three-compartment sink in the kitchen, which increased the potential risk of foodborne illnesses for the residents. Observations revealed that the wash water temperature was consistently documented as 90 degrees Fahrenheit or lower, contrary to the required 110 degrees Fahrenheit. Additionally, the sanitizer water temperature was not maintained at the required 75 degrees Fahrenheit. Interviews with kitchen staff, including a cook and the dietary supervisor, indicated a lack of awareness and understanding of the correct temperature requirements. The dietary supervisor admitted to not knowing the expected wash water temperature and only reviewed logs to ensure documentation was completed, not to verify if the data was within expected parameters. A review of the August 2024 Three-Compartment Sink Log showed discrepancies, with wash water temperatures either exceedingly high or low, and no wash water temperatures documented for the entire month. The sanitizer water temperature was often recorded in the wrong column, and many recorded PPMs were below the expected range. The deficiency was identified as an immediate jeopardy situation, requiring immediate corrective action. The provider's failure to adhere to the Food and Drug Administration's recommendations and their own policy for maintaining proper water temperatures in the kitchen's three-compartment sink posed a significant risk to the health and safety of the residents receiving meals prepared in the facility.
Removal Plan
- DM educated all dietary staff on the 3 sink method, 3 compartment sink order, 3 compartment sink steps, water temperature in a 3 compartment sink, sanitizer temp, and when it is essential to clean and sanitize a utensil, sanitizer per manufacturer recommendations that include submerging for at least 1 minute.
- Education to dietary staff on compartment sink log requirements of testing temps and sanitizer ppm, including action required if temps are not within the requirements.
- DM, primary dayshift cook, primary evening cook, are enrolled in ServSafe Certification.
- All new dietary staff will receive ServSafe certification.
- A new log was created by DM to record wash, rinse, sanitizer water temperatures, and sanitizer ppm with each use, including what to do if temps or ppm are outside of parameters.
- LNHA provided education to DM on the policy and procedure manual, including 3 compartment sink method regulations, job description of the dietary manager including adherence to policies and ensure that sanitary regulations are followed by the entire department.
- Education provided on supervisory roles including ensuring the department adheres to State and Federal regulations, and assuming the authority, responsibility and accountability to carry out the duties of the dietary department, monitor use of equipment and chemicals, and ensuring required documentation is completed and appropriate per regulations.
- Education included reporting to LNHA any areas of concern within the dietary department, equipment, and chemicals.
- Dietary manager will complete ServSafe certification.
Inadequate COVID-19 Management and Infection Control
Penalty
Summary
The facility failed to manage COVID-19 cases effectively among 12 sampled residents, leading to improper precautions and further transmission of the disease. Observations revealed that residents who tested positive for COVID-19 were not isolated properly, with some negative residents remaining in the same room as their positive roommates. Staff were observed not following proper protocols for personal protective equipment (PPE) usage, such as not performing hand hygiene before and after glove use, and not changing N95 masks between rooms. Additionally, there were instances where staff did not wear PPE correctly, such as not securing N95 masks properly or wearing gowns outside of isolation rooms. The facility's records showed a lack of documentation regarding informing residents or their responsible parties about the risks of staying in the same room with COVID-19-positive roommates. Interviews with the Director of Nursing (DON) indicated that while there was an expectation to inform residents and document such communications, this was not consistently done. The facility's COVID-19 outbreak policy required placing residents with confirmed infections in single-person rooms when possible, but this was not adhered to, as evidenced by multiple residents remaining in shared rooms despite positive test results. Further deficiencies were noted in the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and wounds. Observations showed that staff did not consistently use gowns, gloves, or eye protection when providing care to these residents, contrary to the facility's policy. Interviews with staff revealed a lack of awareness and adherence to EBP protocols, with some staff unable to locate necessary PPE or unaware of the requirements for its use. This lack of compliance with infection control measures contributed to the facility's failure to prevent the spread of infections effectively.
Removal Plan
- All COVID-positive residents were moved in with other COVID-positive residents. All negative residents are grouped with well residents with no signs or symptoms of COVID. Other negative residents with known exposure, including resident #6, #38, and resident #8, are in the presumptive area with other presumptive residents.
- Staff have been educated on the importance of keeping all positive residents on isolation for 10 days. Staff are to redirect if they want to come out of their room.
- Staff education was completed by the DON and RN Nurse Specialist to ensure all staff who are currently working and are providing care to positive and presumptive residents knew how to properly DONN and DOFF PPE. PPE is put on prior to entering positive and presumptive rooms. This includes removing the gloves and gown inside the room and performing hand hygiene. The removal of the eye protection and mask happens outside the room. Masks and eye protection are discarded. Hand hygiene is performed again. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on properly wearing an N95 mask. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on proper hand hygiene after DOFFING PPE prior to assisting another resident. All those not on shift will be educated prior to them coming on shift.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Deficiency in Diabetic Care and Physician Notification
Penalty
Summary
The provider failed to ensure proper care and services for diabetic residents, specifically in monitoring blood sugar levels and notifying physicians when levels were outside the normal range. This deficiency affected four out of seven diabetic residents, leading to instances where blood sugar levels were not managed according to accepted clinical standards. Interviews and record reviews revealed that interventions and timely follow-ups were inconsistently documented, contributing to the deficiency. Resident 38, who has type 1 diabetes mellitus and other health conditions, experienced fluctuating blood sugar levels. On multiple occasions, her blood sugar dropped to dangerously low levels, yet there was no documentation of interventions or physician notifications. Similarly, resident 22, with type 2 diabetes and other serious health issues, had several high blood sugar readings without any record of physician notification. Resident 3, also with type 2 diabetes, had high blood sugar levels recorded without any documented physician contact. Resident 20, who is severely cognitively impaired, had high blood sugar levels without physician notification as well. The facility lacked a written policy on hypoglycemia management or diabetic care, relying instead on standing orders that were not reviewed by the current DON. Interviews with staff, including the ADON, revealed inconsistencies in the process for managing low or high blood sugar levels, with some staff unsure of the facility's policy. The deficiency was further highlighted by the lack of documentation of physician notifications for numerous blood sugar readings outside the normal range.
Removal Plan
- Diabetic residents #3, #20, #22, and #38 who receive insulin will be managed with the glycemic management protocol given by the medical directors' guidelines.
- Nurses (RN and LPN) as well as medication aides have been educated on hypoglycemia and hyperglycemia protocols.
- Nurses are to contact each individual residents' provider in event of a low or high blood sugar reading.
- Nurses were educated to document interventions for low or high blood sugar within the resident's EMR.
- Nurses have been educated on the importance of following each individual resident's guidelines given by the resident's medical provider to properly manage diabetes.
- Nursing staff education was completed by the DON and ADON to ensure those who are currently working are providing appropriate glycemic care and the steps to follow in the event of a low or high blood sugar reading.
- Glycemic management protocol instructs that the nurse on duty will contact the residents' provider during clinical hours or their hospital on-call provider after business hours.
- All nurses and medication aides not on shift will be educated prior to them coming on shift.
- All nurses and medications aides were educated on glycemic management protocols.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Failure to Ensure Proper Sanitation Levels in Kitchen
Penalty
Summary
The provider failed to ensure that staff were able to verify the chemical sanitation level required to sanitize the dishes used for preparation and serving residents' food. This deficiency was identified through observations, interviews, and record reviews. The survey revealed that the dishwasher's chemical sanitation was not functioning, and staff were not aware of any process to follow when this occurred. Additionally, staff could not accurately verify the chemical sanitation level of the dishwasher due to the use of expired test strips. During the survey, it was observed that the sanitizing testing strips located by the three-compartment sink had expired. Interviews with dietary staff confirmed that these expired strips were being used to test the sanitizing solution, which was not at the correct parts per million (PPM) for effective sanitization. The Nutrition and Food Services Supervisor confirmed that the test strips were outdated and that there were no other test strips available for use. Furthermore, the dishwasher sanitizer was tested and found to be insufficient, with a reading of 10 ppm instead of the required 50 ppm. The deficiency was further compounded by the lack of awareness among staff regarding the expiration of test strips and the proper procedures to follow when the dishwasher was not functioning correctly. The provider's policies and procedures for sanitizing food contact surfaces and warewashing were not effectively implemented, as evidenced by the expired test strips and the inadequate sanitizing solution levels. This failure increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen and served to the residents.
Removal Plan
- Provide dishwasher manufacturer manual and disinfectant information to support instructions are being followed and appropriate sanitation is occurring.
- Use disposable paper plates, cups, and silverware until dishwasher is running appropriately.
- Place new non-expired strips in for the 3 comp sink.
- Remove all expired strips in kitchen.
- Wash all dishes in the 3-comp sink until dishwasher is fixed to verify levels.
- Implement the use of a Monitoring Use of Ecolab disinfectant Test Strips form for staff to sign off on expiration date of a cartridge when replaced and label in the cartridge holder on the wall.
- Complete education with all dietary staff on proper procedure for non-working dishwasher and education on non-expired test strips with return demonstration.
- Educate all staff via PCC Communications that kitchen staff must ensure all chemical test strips are not expired for the dishwasher and the 3 comp sink.
- Add to the TELS Service Provider a task for Director of Environmental Services to monitor weekly if a cartridge is near expiration and needs replacement.
- Contact EcoLab to fix dishwasher. In the meantime, try a new bucket of Ultra San Ecolab 5 gallon liquid sanitizer in the dishwasher and retest.
Dishwasher Temperature Noncompliance
Penalty
Summary
The provider failed to maintain the dishwasher wash cycle temperature at a minimum of 120 degrees Fahrenheit as required by the manufacturer's manual. Observations and interviews revealed that the dishwasher's wash cycle temperatures were consistently below the required threshold, with recorded temperatures ranging from 100 to 115 degrees Fahrenheit over several days. There were also numerous instances where wash, rinse, and chemical sanitation level checks were missing. The facility's dishwasher was serviced monthly by a vendor, but the issue persisted, and the administrator was not notified of the low-temperature readings. Interviews with dietary staff confirmed that the dishwasher's external thermometer readings matched those of a thermometer run through the dishwasher, both indicating temperatures below the required 120 degrees Fahrenheit. The dietary aide acknowledged that the wash temperature should be 120 degrees Fahrenheit. Despite the lack of gastrointestinal illness reported in the past three months, the administrator expected staff to report low-temperature readings, which did not occur. A review of the ECOLAB service report and the facility's cleaning policy revealed discrepancies in temperature requirements. The ECOLAB report noted a wash temperature of 100 degrees Fahrenheit and advised monitoring for compliance. The facility's policy inaccurately stated that the dishwasher, a chemical sanitizing machine, required temperatures between 90 and 110 degrees Fahrenheit, conflicting with the manufacturer's specification of a minimum of 120 degrees Fahrenheit.
Removal Plan
- Dietary staff were instructed to use paper plates and bowls and to use the three-compartment sink for cleaning and sanitizing of all utensils/pots/pans, etc. that are not disposable.
- Administrator met with Dietary staff and reviewed the policy and procedure on the use of the three-compartment sink as well as instructions located above the three-sink area.
- Administrator spoke with the representative from ECO Lab concerning this noncompliance. Recommendation to install a booster water heater to the current dishwasher unit.
- Administrator spoke with [Name] from [Name] Heating and Cooling and arranged for a service call to complete wiring for the installation of the booster water heater.
- [Name] Heating and Cooling presented to facility. Conversation was held with [Name] from [Name] Heating and Cooling and [Name] from ECO Lab via phone. [Name] from ECO Lab and [Name] from [Name] Heating and Cooling will be installing the booster water heater.
- Administrator completed and implemented new Dishwasher Temperature Policy and Low-Temperature Dishwasher Chart.
- Dietary Staff mandatory education will be held to review the Dishwasher Temperature Policy and Procedure as well as the Low-Temperature Dishwasher Chart.
- Daily audits to ensure compliance with the dishwasher temperature will be completed by this Administrator and will report findings to the QAPI Committee. Following continuous compliance, daily audits will change to weekly audits. The continuation of audits will be reviewed monthly during QAPI Committee meetings.
Inadequate Supervision Leads to Resident Self-Harm
Penalty
Summary
The provider failed to provide adequate supervision for a resident to prevent actions of self-harm. The resident was observed in his room with multiple open areas on his bilateral lower legs, some of which were actively bleeding, while holding a sharp instrument. Staff interviews revealed that they were aware the resident had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. The resident's care plan allowed him to have sharps in his possession to remove perceived bugs from his skin. The resident had a history of picking at his skin and cutting himself, believing there were bugs under his skin. He had been seen by a behavioral counselor due to suicidal ideations and hallucinations. Despite this, the resident was allowed to keep sharps in his room, and staff were aware of his behavior but did not adequately supervise or intervene to prevent self-harm. Interviews with staff indicated that the resident was independent, allowed to leave the premises, and would purchase items, including sharps, from a store. The resident's care plan documented his behavioral symptoms, including cutting and picking at his skin, and allowed him to keep sharps in his room. The care plan noted that the resident declined to follow physician-recommended advice and would not allow nurses to care for his open areas. Staff were aware of the resident's behavior and the presence of sharps in his room, but there was no inventory or tracking of the sharps, and the resident's wounds were not regularly documented or treated by nursing staff.
Removal Plan
- All sharps have been removed from Resident 20's room.
- Psychiatry, primary care provider and counselor have been notified for guidance in managing any adverse behavioral changes.
- Resident 20 has been re-educated on hand hygiene, sharps in his room, infection prevention to include covering wounds.
- Updates to the care plan include removing sharps, offering tubi-grips for arms and lower legs for covering of wounds when leaving his room, handwashing education, wound assessment completed, one-hour check while in the facility for behaviors given resident psychiatric history then re-evaluate.
- Center of Excellence for Behavioral Health in Nursing Facilities contacted with expected response.
- Director of nursing spoke to Resident 20 about dressing changes.
- Resident agreed to let nursing staff change dressing twice a day.
- Nursing staff will monitor for any signs of infection during dressing changes and notify the physician if any noticed. These will be documented on Resident 20's treatment.
- Nursing will remove soiled towels and washcloths when in his room providing dressing changes. This has been included in the treatment plan and added to the certified nursing assistant (CNA) flowsheet.
- Resident was informed that he would not need to buy wound/dressing supplies.
- Sharps removed from resident 20's room.
- All other current resident rooms were checked for sharps and any of concern were removed.
- Discussed with Resident 20 that his bags would be checked upon return from shopping.
- Resident signed previous acknowledgment form that he agreed to staff removing sharps that he may bring back.
- Staff will conduct random room checks and will chart in Resident 20's chart as a treatment.
- This has been added to Resident 20's treatment plan and CNA flowsheet.
- Added a treatment order for nursing documentation for behavior/mood of resident 20.
- Resident 20's behavior documentation will be reviewed at interdisciplinary team (IDT) meetings and as needed with adjustments to care/treatment plan as warranted.
- Admission packet updated regarding review of sharps for safety.
- Resident 20's primary contacts have been re-educated on notifying staff prior to bringing/getting sharps items to resident via email.
- Resident 20 has been re-educated on proper hand hygiene for infection prevention and sharps.
- Staff have been re-educated on sharps in rooms and planned review of infection prevention practices related to transmission through OnShift.
- They receive this education annually at minimum.
- A skills fair reviewing infection prevention is scheduled and annually for staff.
- Sharps restriction added to admissions packet.
- Staff re-educated on infection prevention practices and safety of all residents related to sharps in resident rooms.
- Staff were educated through onshift message about the removal of sharps for any resident.
- Additional education provided to nursing staff related to resident 20 returning from shopping, the need to look in resident 20's bags for any sharp objects that staff would need to remove and secure in the medication room, staff will reiterate to resident that he is not able to have those items in his room.
- PRN treatment order added to check bags upon returning from shopping outings.
- Staff will also be educated on the random room checks that will be conducted on Resident 20's room for sharps found, those items will be removed and secured in the medication room.
- Treatment order added to document these random room checks for Resident 20, also added to CNA flowsheet to check room twice a day.
Resident Elopement and Fall Risk Management Deficiencies
Penalty
Summary
The report details a deficiency involving the elopement of a resident with severe cognitive impairment from a long-term care facility. The resident, who had a history of elopement and was assessed as a high risk for elopement, managed to leave the facility without staff knowledge. The resident was wearing a wander guard, a device intended to prevent such incidents, but there was no documentation of its functionality being checked as required. The elopement was not immediately detected, and the resident was found outside the facility and returned after a significant delay. Another deficiency involved a resident with cognitive impairment and a history of falls who was found on the floor, naked and covered in feces, after a call light went unanswered for an extended period. The resident had a history of falls and required assistance for all activities of daily living. Despite this, the call light system, which should have alerted staff to the resident's needs, was not responded to in a timely manner. The resident's care plan did not adequately address her high fall risk, and staff failed to anticipate her needs, leading to multiple falls. Interviews with staff revealed a lack of awareness and adherence to policies regarding resident safety and monitoring. Staff were not consistently checking the functionality of safety devices like wander guards, and there was a failure to respond to call lights promptly. The facility's policies on monitoring high-risk residents and ensuring their safety were not effectively implemented, contributing to the deficiencies observed.
Removal Plan
- A message was sent to all employees that summarized the education summary of elopement. This serves as the immediate education for all employees. If staff are not able to complete education, they will be required to complete the make-up prior to their next shift.
- RN S was educated on the process for calling DON/Administrator immediately when resident safety is at risk-including elopements. The nurse was also educated on the next step of the policy to initiate a head count of all residents when a door alarm is sounded with no explanation.
- Certified nursing assistant (CNA) T was noted to have missed a toileting round of resident 3. This would have decreased the time of the residents' elopement. The CNA T received a final corrective action for lack of rounding during this shift. This standard will be upheld for any employees that are found to have failed to complete their rounding as ordered/recommended.
- All staff were educated on the importance of rounding on all residents multiple times a shift. Residents with high fall and elopement to chart in the hallways so residents can be in eye site.
- All staff were educated on utilizing our call system as all exit doors are on the call system to notify all staff if an exit door is alarm on the scrolling screen and the radios.
- Assessment of resident was completed, and vital signs taken.
- An elopement drill was completed with day shift. Education was provided to staff involved with elopement.
- A potential elopement alert was initiated due to a phone call from someone in the community stating a resident was outdoors near [NAME] Road. Staff responded to code and facility did head count and everyone was accounted for.
- Hallway and department education is being completed with all staff regarding elopement processes and policy review. Elopement policy/procedure was reviewed, explained what an elopement is, who is considered an elopement risk, steps to take when a potential elopement occurs, who to notify if a resident does elope and how to respond to door alarms and completing head counts if no residents were found when alarm was responded to.
- Resident 3's physician was out to facility and updated again on recent elopement events. Resident 3's physician ordered lab work-up on him as this an increase in his normal behaviors. He also would like an update on how he is doing.
- Elopement Drills will be completed weekly x4. These will be completed on shifts, different days of the week and different locations within the building. Then every other week x 4 weeks.
Failure to Protect Residents from Abuse by Co-Resident
Penalty
Summary
The provider failed to protect two residents from abuse by another resident, leading to a deficiency. Resident 4 was observed inappropriately touching Resident 1, who has severe cognitive impairment due to dementia and psychosis, and Resident 2, who has dementia and amnesia. Both residents were unable to consent or defend themselves. Despite these incidents, the care plans for Residents 1 and 2 were not updated to reflect that they had been victims of inappropriate touching. Interviews with staff revealed that Resident 4 had a pattern of inappropriate behavior, including touching other residents' thighs and breasts. Staff members, including a registered nurse and certified nursing assistants, reported these incidents to the charge nurse and administration. However, the facility's response was inadequate, as the care plans for the affected residents were not updated, and there was a lack of immediate action to prevent further incidents. The facility's policy on abuse and neglect requires prompt investigation and reporting of such incidents, as well as immediate action to prevent further abuse. However, the facility did not adhere to these procedures, as evidenced by the lack of updated care plans and insufficient measures to protect the residents from further abuse by Resident 4. This failure to follow policy and ensure resident safety resulted in a deficiency being cited by the surveyors.
Removal Plan
- 30-minute checks on resident 4 initiated to ensure the safety of all residents.
- Medical director discontinued the use of Sildenafil and will monitor the use of other medications that could lead to sexual temptations.
- Resident 4 was scheduled to be evaluated by a psychiatry provider to rule out dementia or other medical conditions that could cause the more frequent sexual behaviors.
- Resident 4 was seen by a psychiatry provider.
- Care plans have been updated.
- Education was provided to all staff.
- Managers will provide the education to staff that were not in the building and staff will be required to receive the education before they start their next shift.
- All staff will continue to monitor behaviors and safety for all residents.
- Interventions in place will be assessed and will be modified if needed to make sure the issue is being resolved appropriately.
Latest Citations in South Dakota
Surveyors found that respiratory equipment such as nebulizers and BiPAP machines were not properly cleaned or stored between uses for several residents with COPD, with masks and tubing left uncovered and wet. Shared personal care items and an uncleanable whirlpool bath chair were observed in use, and clean linen closets contained unclean items, increasing the risk of contamination. The facility also lacked a water management plan to assess and prevent Legionella, and staff interviews confirmed gaps in infection control practices and policies.
The facility did not maintain consistent on-site administrative oversight, with the administrator of record only present weekly and a secondary administrator covering once a week while also managing another facility. Most day-to-day management and administrative duties were delegated to the DON and business manager, leading to difficulties in fulfilling their primary responsibilities and impacting the quality management and well-being of all residents.
The facility did not ensure its QAPI program effectively identified and corrected quality deficiencies, as the QAPI committee and DON were unaware of multiple areas of non-compliance, including medication management, care planning, assessments, oxygen equipment handling, trauma-informed care, food storage, and infection control. The QAPI committee was only focused on a limited set of issues and failed to monitor or address several critical areas impacting resident care.
The QAA committee did not consistently include an administrator, owner, board member, or other leadership representative, as required. Over a 15-month period, the administrator attended only two meetings, and no other leadership figures were present, despite policy stating their responsibility for QAPI oversight. Department managers, the medical director, and the consultant pharmacist attended, but leadership involvement was lacking.
The facility did not ensure Enhanced Barrier Precautions (EBP) were followed for two residents with wounds, as required by its infection control policy. PPE such as gowns and gloves were not available at the point of care, staff inconsistently used PPE during high-contact activities, and there was confusion among staff about when and where EBP should be applied, including in therapy areas.
The facility did not follow its antibiotic stewardship policy, as the DON admitted to inconsistent use of required infection surveillance forms, lack of documentation of symptoms before contacting physicians, and failure to monitor infection trends or conduct required audits. The facility also did not complete annual summaries, hold stewardship meetings, or maintain an antibiogram, and the DON was unaware of elevated UTI rates among long-stay residents.
The designated infection preventionist, who was the DON, had not completed the required CDC infection prevention and control training, having finished only 5 of 23 modules and lacking a certificate of completion.
A cook did not change gloves or wash hands after touching multiple surfaces and items during meal service, continuing to handle ready-to-eat foods with the same gloves. Unsanitary conditions were also observed in the kitchen, including food debris on equipment and uncleanable surfaces. Staff and management confirmed that cleaning schedules and infection control policies were not followed.
Several residents self-administered medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or required physician's orders. Medications were left at the bedside or in resident rooms, sometimes expired or unlabeled, and care plans did not address self-administration or medication storage. Facility staff confirmed that no residents had been formally assessed or authorized for self-administration, contrary to facility policy.
Several newly admitted residents did not have complete baseline care plans within 48 hours of admission, with missing documentation of review and provision to residents or their representatives. Some care plans lacked essential information such as active diagnoses and signatures, and residents reported not recalling any review or receipt of their care plans. The facility's policy did not require review of the baseline care plan with the resident or representative within the specified timeframe.
Infection Control Deficiencies in Respiratory Equipment, Shared Items, Linen Storage, and Water Management
Penalty
Summary
Surveyors identified multiple deficiencies in infection prevention and control practices within the facility. Observations revealed that nebulizer machines and equipment for three residents with chronic obstructive pulmonary disease (COPD) were not properly cleaned or stored. The nebulizer masks and tubing were left attached to the machines, uncovered, and with wet medication chambers between uses. In one case, a BiPAP machine mask was found resting in an uncovered basin on the floor, alongside other items, and was not cleaned or stored as required. Staff interviews confirmed that cleaning and storage protocols were not consistently followed, and care plans lacked specific instructions for these procedures. Further deficiencies were observed in the maintenance and use of shared equipment and personal care items. The whirlpool bath chair in the shower/tub room had rusted, cracked, and bubbled surfaces, making it uncleanable. Shared, partially used, and unlabeled personal hygiene products were available for use among residents, contrary to staff expectations that each resident should have their own products to prevent cross-contamination. There was no policy in place regarding the shared use of personal hygiene items, and staff acknowledged the risk of infection control concerns due to these practices. Additional issues were found in the storage of clean linens, where unclean items such as walkers, shoes, personal care items, and opened packages of briefs were stored alongside clean linens in designated linen closets. This practice was contrary to facility policy, which required that only clean linen be stored in these areas to prevent contamination. The facility also lacked a water management plan to assess, prevent, and monitor for Legionella and other waterborne pathogens, with no policies or testing protocols in place.
Inadequate Administrative Oversight and Delegation of Duties
Penalty
Summary
The facility failed to ensure effective and efficient use of its resources due to inadequate administrative oversight and inconsistent presence of the administrator. Administrator A, who was the administrator of record, was only present in the building weekly, and when unavailable, administrator B, who was also a full-time administrator at another facility, would be present once a week. Department managers such as the DON, business manager, and dietary manager were expected to be in the building full-time, but significant administrative duties were delegated to the DON and business manager. The DON reported struggling to fulfill her nursing responsibilities while also covering administrative tasks, and noted that administrator A's response to issues was not always timely. The business manager was unavailable during the survey for interview. Interviews with staff revealed that the day-to-day operations and quality management of the facility were largely handled by the DON and business manager, with administrators only intervening when issues arose that could not be addressed by these managers. The administrator job description required direct oversight and accountability for the facility's operations, but this was not consistently met. The lack of regular, on-site administrative supervision led to management issues being delegated to department heads, impacting their ability to perform their primary roles and potentially affecting the overall well-being of the 26 residents in the facility.
Failure to Identify and Address Quality Deficiencies Through QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified and corrected quality deficiencies throughout the facility. The Director of Nursing (DON) was responsible for overseeing the quality management program, including QAA committee meetings and QAPI projects. However, during an interview, the DON stated that while each department manager conducted audits and discussed them with the QAPI committee, the committee was only focused on a limited set of issues such as restraints, skin infections, call light accessibility, and communication with medical providers regarding lab results. The DON was unaware of several areas of non-compliance, including medication administration and storage, timely provision of baseline care plans, accurate care plan revisions, completion of required assessments, proper handling of oxygen equipment, trauma-informed care assessments, safe food storage, and infection prevention and control practices. The QAPI committee had not identified or addressed these significant quality issues, and the DON confirmed that the QAPI process had not been effective in identifying problems that could impact resident care. The facility's QAPI policy stated that the program should encompass all care and services affecting clinical care, quality of life, resident choice, and care transitions, and that the governing body and management were responsible for identifying and prioritizing problems based on performance data. Despite this, the QAPI committee was not aware of or monitoring several critical areas of deficiency, as confirmed by the DON.
QAA Committee Lacked Required Leadership Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee included the required members, specifically an administrator, owner, board member, or other individual in a leadership role, as mandated. Over a 15-month period, attendance records showed that the administrator attended only two QAA meetings, and there was no evidence that the owner, a board member, or another leadership designee attended any meetings. Interviews with the medical director and DON confirmed that the administrator was not routinely present at QAA or QAPI meetings, and the DON noted that the administrator had only recently attended a meeting after a prolonged absence. The QAA committee was otherwise comprised of department managers, the medical director, and the consultant pharmacist, but lacked consistent leadership representation. The facility's QAPI policy outlined that the governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program, including identifying and prioritizing problems, incorporating input from staff and residents, and ensuring corrective actions are effective. Despite these policy requirements, the facility did not provide evidence that leadership was actively involved in the QAA process during the review period, as required by regulation.
Failure to Implement Enhanced Barrier Precautions According to Policy
Penalty
Summary
Surveyors identified that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own infection prevention and control policy for two residents who were on EBP. Observations revealed that signage indicating EBP was present on the doors of both residents, but there was no personal protective equipment (PPE) such as gowns or gloves available at or near the entrances to their rooms. Staff interviews confirmed inconsistent understanding and application of EBP, with some staff unaware of the reasons for EBP signage or the correct PPE requirements, and others storing gowns in resident dressers or closets rather than at the point of care. For one resident, who had recently returned from the hospital with a surgical incision and staples, there was no documentation in the electronic medical record (EMR) indicating the need for EBP, and the resident herself was unaware of the reason for the precautions. For the second resident, who had a surgical wound on his right lower leg requiring daily dressing changes, staff wore gloves but not gowns during care, and PPE was not accessible at the room entrance. The care plan for this resident specified that both gloves and gowns should be used for high-contact activities, but this was not consistently followed. Further observations in the therapy area showed that staff did not use PPE when providing direct care, such as assisting with transfers and mobility, to residents on EBP. Interviews with therapy and nursing staff revealed gaps in knowledge regarding when and where PPE should be used, particularly outside of resident rooms. The facility's policy required EBP, including gown and glove use, during high-contact activities both in resident rooms and in shared areas like the therapy gym, but this was not adhered to in practice.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as outlined in its own policy. The Director of Nursing (DON), who also served as the infection preventionist, acknowledged that the facility was not consistently using the SBAR form based on McGeer criteria for infection surveillance, particularly for suspected urinary tract infections (UTIs). The DON admitted that staff often bypassed the required documentation of symptoms before contacting physicians, and the facility was almost always noncompliant with this process. Additionally, the DON did not monitor infections by resident location to identify potential clusters and only reviewed monthly antibiotic use reports from the contracted pharmacy, which lacked information on diagnosis or appropriateness of antibiotic use. Further review revealed that the facility did not adhere to several key components of its antibiotic stewardship policy. The DON did not complete an annual summary of antibiotic use, failed to hold antibiotic stewardship meetings, did not perform random audits of antibiotic prescriptions, and did not track at least one outcome measure associated with antibiotic use monthly. The facility also lacked an antibiogram, which is required to guide antibiotic use protocols, and did not provide annual feedback to prescribing physicians regarding their antibiotic use for residents. Documentation related to the stewardship program, such as meeting minutes and feedback reports, was not maintained as required by policy. The DON was unaware that the facility's infection rate for UTIs among long-stay residents was above state and national averages, as reported in the facility's quality measures. The facility's policies required the infection preventionist to report findings of surveillance activities, including infection rates and types, to the QAA committee, physicians, and other staff, but these activities were not being carried out as described. The facility's own assessment claimed that infections were tracked and trended, and that there were regular meetings to discuss infection control and antibiotic stewardship, but these practices were not substantiated by the DON's statements or by documentation.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that the designated infection preventionist, who was the Director of Nursing (DON), had completed the required specialized training in infection prevention and control. The DON was hired in October 2021 and began the CDC's Nursing Home Infection Preventionist Training course in October 2022. However, as of the time of the survey, the DON had only completed 5 out of the 23 required modules and was not aware that the course was incomplete. Record review confirmed the lack of a certificate of completion for the full course, and the DON acknowledged not having finished the training.
Failure to Follow Food Safety and Sanitation Practices in Dietary Services
Penalty
Summary
Surveyors observed that a cook failed to follow standard food safety practices during meal service by not changing gloves or washing hands after touching multiple surfaces and items, including food containers, utensils, meal cards, microwave doors, and food packaging. The cook continued to use the same pair of gloves throughout the meal service, including when handling ready-to-eat food items, and admitted that it was her normal practice not to change gloves during food service. The dietary manager and another cook confirmed that gloves should have been changed after touching multiple surfaces and that tongs should have been used to retrieve certain food items. Additionally, the kitchen environment was found to be unsanitary, with food spatter and debris observed on pans, lids, prep table shelves, and the steam table. The steam table also had exposed bare wood, making it uncleanable. The dietary manager acknowledged that cleaning schedules for kitchen equipment had not been followed, and records showed inconsistent documentation of cleaning. Facility policies required cleaning and sanitizing of work surfaces and equipment after each use, as well as proper glove use and handwashing, but these were not adhered to during the observed period.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications were properly assessed for their ability to do so safely and did not obtain the required physician's orders for self-administration, as outlined in facility policy. Four residents were identified as self-administering medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or care plan interventions addressing their ability to self-administer. In several cases, medications were left at the bedside or in resident rooms without proper labeling or documentation, and some medications were expired or not prescribed for current use. One resident with moderate cognitive impairment was observed self-administering nebulizer treatments and using topical medications left at his bedside, including an expired antibiotic ear drop that he used for itching. He also had an antacid medication left at his bedside for self-administration without a physician's order or assessment. Another resident, who was cognitively intact, self-administered prescription cream and powder with physician's orders to keep the medications in his room, but there was no documentation of an assessment for his ability to self-administer these medications, nor was this addressed in his care plan. Additional residents were found to have medications such as Vicks Vapor Rub and nebulizer treatments in their rooms, which they self-administered without physician's orders or documented assessments. Facility staff, including LPNs and the DON, confirmed that no residents had been formally assessed for self-administration of medications and that physician's orders for self-administration were not in place. The facility's policies required both an assessment and a physician's order for self-administration, but these procedures were not followed, and the care plans did not address self-administration or medication storage for the affected residents.
Failure to Complete and Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and document baseline care plans and provide written summaries to residents or their representatives within 48 hours of admission for four recently admitted residents. Record reviews showed that baseline care plans were either incomplete, missing required sections such as active diagnoses, staff and resident signatures, or not documented as being reviewed with the resident or their representative. In several cases, there was no evidence that a copy of the baseline care plan was offered or provided to the resident or their representative. Interviews with the residents revealed that they did not recall reviewing their care plans or being offered copies within the required timeframe. Specific observations included residents with moderate cognitive impairment, use of medical devices such as CPAP machines and equalizer boots, and recent hospitalizations. The facility's policy required an interim plan of care to be developed within 24 hours of admission but did not specify that the plan must be reviewed with the resident or representative within 48 hours. The DON confirmed that several baseline care plans were incomplete and lacked documentation of review or provision to the residents or their representatives.
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