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)
Latest Citations in South Dakota
Two nurses failed to initiate CPR for a resident with Full Code status who was found unresponsive, despite clear facility policy and the resident's advanced directive requiring life-sustaining measures. The resident, who had advanced cervical cancer and a history of significant bleeding, was discovered deceased with no resuscitation efforts made by staff present, in direct violation of established procedures.
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.
A CNA/activity staff member failed to report residents' allegations of neglect, documented during a resident council meeting, to the administrator as required by policy. This resulted in a delay of several days before the administrator and the SD DOH were notified, violating the required 24-hour reporting timeframe for such allegations.
A resident with multiple comorbidities and a history of pressure ulcers developed new wounds on the lower legs and foot. Staff failed to promptly assess, document, and communicate these wounds, leading to delays in treatment and a lack of timely interventions. Inaccurate information was sent to the physician, and several days passed without care for the wounds, resulting in the resident's condition worsening and requiring hospitalization. Facility policies for skin integrity monitoring and response were not followed, contributing to the deficiency.
A resident with significant medical needs and high risk for pressure ulcers developed untreated blisters that progressed to a stage 2 pressure ulcer after staff failed to implement wound care orders, document assessments, or communicate with the wound nurse and primary care provider, resulting in a lack of timely intervention.
A CNA did not secure a safety belt on a whirlpool bath chair while bathing a resident who was totally dependent on staff for transfers and mobility, resulting in the resident sliding out of the chair and falling to the floor. The resident had multiple complex medical conditions and required two-person assistance, but the use of the safety belt was not standard practice at the time. Staff interviews and observations confirmed that the safety belt was available but not routinely used prior to the incident.
Staff did not consistently use required PPE, such as gowns and gloves, when providing care to residents on enhanced barrier precautions, and failed to clean shared equipment like mechanical lifts after each use. Multiple residents reported that staff typically wore gloves but not gowns, and urinals without lids were left in rooms. Additionally, a urine spill remained uncleaned for hours, and staff were unaware until notified. These actions did not follow facility infection prevention policies.
A CMA administered medications intended for one resident to another, resulting in the recipient experiencing nausea, vomiting, and anxiety, and requiring evaluation at the emergency department. The error was recognized and reported by the CMA, but other staff administering medications were not formally educated or re-educated about the incident or medication administration policy, and there was no evidence of facility-wide education or monitoring following the event.
Three residents with varying degrees of cognitive and physical impairment experienced falls or lacked access to recliner controls due to the facility's failure to assess recliner safety, update care plans, and educate staff. Care plans were not revised to reflect changes in residents' conditions or new interventions after falls, and staff were inconsistently informed about recliner safety protocols, resulting in inadequate supervision and accident hazard prevention.
Three residents experienced falls due to staff not following safety protocols for equipment use, including failure to secure safety belts and lock wheels on bath chairs and mechanical lifts. In one case, a resident suffered cervical fractures after falling from an unsecured bath chair, and staff did not complete required neurological assessments. Other incidents involved residents falling during transfers when safety straps were not used, despite staff being aware of these requirements. Care plans were not updated after these events, and facility policies for safe equipment operation were not consistently followed.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Two registered nurses, the social services director and the interim director of nursing, failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive, despite the resident being designated as Full Code/Full treatment. Upon discovery, the resident was pale, ashen, cool to the touch, had no visible movement, and was without a pulse. There was a significant amount of blood on the bed linens, and the resident was ultimately confirmed deceased. Staff present did not follow the facility's CPR policy, which required initiation of life-sustaining measures for residents with Full Code status. The resident had a history of cervical cancer, suspected to be stage IV with possible liver metastasis, and had experienced post-menopausal bleeding for several months prior to admission. Her care plan included an advanced directive specifying Full Code/Full Resuscitative measures in the event of cardiac arrest. Despite this, no life-sustaining measures were initiated by the immediate staff upon finding her unresponsive. Interviews revealed that staff were aware of her code status but made the decision not to start CPR, with one staff member stating that she did not want to "mutilate her body like that." Additional interviews indicated that some staff, including a CNA, had not received current CPR training, though all licensed nurses were required to be CPR certified. The facility's policy outlined that CPR should be initiated for residents with Full Code status unless specific conditions were present, such as dependent lividity or decomposition, which were not documented in this case. The failure to initiate CPR was a direct violation of both the resident's documented wishes and the facility's established policy.
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 Timely Report Allegations of Neglect from Resident Council
Penalty
Summary
A certified nursing assistant (CNA) who also served as activity staff attended and documented a resident council meeting where residents raised concerns about personal care, including issues such as residents appearing unkempt at meals and activities, exposure of body parts, and lack of privacy during care. These concerns were recorded as allegations of neglect in the meeting minutes. However, the CNA did not report these allegations to the administrator as required by facility policy, resulting in a delay in notifying the appropriate authorities. The administrator was not made aware of the allegations until five days after the meeting, and the South Dakota Department of Health (SD DOH) was notified six days after the initial allegations were made. Facility policies require that all allegations of abuse or neglect be reported to the administrator immediately, and to state authorities within 24 hours if there is no serious bodily injury. The failure to report the allegations in a timely manner led to noncompliance with both facility policy and regulatory requirements.
Failure to Timely Assess, Document, and Treat Skin Injuries Resulting in Hospitalization
Penalty
Summary
The facility failed to provide quality care in the prevention and management of skin injuries for a resident with significant medical complexities, including chronic heart failure, peripheral vascular disease, malnutrition, and Brown-Sequard syndrome. The resident was dependent on staff for repositioning and transfers, and had a history of pressure ulcers, including an unstageable ulcer on the coccyx. Despite having a care plan and physician orders in place for regular skin assessments and wound care, staff did not consistently evaluate, document, or communicate changes in the resident's skin condition, particularly regarding new wounds on the left lower leg, left foot, and right lower leg. Multiple breakdowns in communication and documentation were identified. When new wounds were first observed, the responsible nurse did not complete a skin evaluation or document the findings, and there was confusion regarding the correct location of the wounds in communications with the physician. Treatment orders were delayed and not implemented promptly, and there were several days where no interventions were provided for the resident's leg wounds. Staff interviews revealed uncertainty about documentation procedures and a reliance on the wound care nurse to address new skin issues, rather than immediate action by the nurse who identified the problem. The lack of timely assessment, accurate documentation, and prompt intervention resulted in the resident's wounds worsening, ultimately requiring hospitalization. The facility's own policies required daily skin inspections, prompt reporting of changes, and immediate implementation of interventions for new or worsening wounds, but these procedures were not followed. The failures in evaluation, communication, and treatment placed the resident at risk for serious harm and led to the identification of an Immediate Jeopardy situation by surveyors.
Failure to Implement Wound Treatment Orders and Prevent Pressure Ulcer Development
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, dysphagia, diabetes with neuropathy, and aphasia, was admitted to the facility and identified as being at high risk for developing pressure ulcers based on Braden Scale assessments. The resident was nonverbal, required total assistance for all activities of daily living, and was unable to reposition herself in bed. Initial skin assessments upon admission showed intact skin, but subsequent documentation was lacking until after a hospitalization. On one occasion, a registered nurse documented the presence of two blisters on the resident's buttocks and notified a telemedicine provider (eCare), who gave orders for wound care, including the application of Opti Foam dressings and continued repositioning. However, there was no evidence that these orders were entered into the electronic medical record, implemented, or communicated to the wound nurse, primary care provider, or the resident's representative. There was also no documentation of a skin assessment of the blisters, nor was there evidence of regular repositioning or monitoring as required by the resident's care plan and facility policy. The only documentation related to the blisters was a progress note and a scanned eCare note, neither of which were signed or acknowledged by nursing staff. Interviews with staff revealed confusion and lack of recall regarding the wound care orders and the resident's condition. The facility's skin integrity policy required systematic assessment, documentation, notification, and intervention for skin impairments, but these steps were not followed. As a result, the blisters went untreated for several days, and the resident developed a stage 2 pressure ulcer on her sacrum, which was identified during a subsequent hospital admission. There was no evidence that the required notifications, assessments, or interventions were completed in accordance with facility policy.
Failure to Use Bath Chair Safety Belt Results in Resident Fall
Penalty
Summary
A certified nursing assistant (CNA) failed to use the safety belt on a whirlpool bath chair while bathing a resident who was totally dependent on staff for transfers and mobility. The resident, who had been admitted the previous day, was assisted into the bath chair using a full-body mechanical lift by two CNAs. After the bath, while the resident was still seated in the bath chair, the CNA wheeled the resident away from the tub without securing the safety belt, resulting in the resident sliding out of the chair and falling to the floor. The resident involved had multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, restlessness, agitation, dysphagia, major depressive disorder, gastrostomy status, encephalopathy, Type 2 diabetes mellitus with neuropathy, aphagia, and acute respiratory failure with hypoxia. The resident was nonverbal at baseline and required total assistance for transfers and bed mobility, as documented in her care plan. At the time of the incident, the care plan specified two-person assistance for transfers but did not yet include specific interventions for bathing safety or the use of the bath chair safety belt. Interviews and observations revealed that, prior to the incident, it was not standard practice or policy at the facility to use the bath chair safety belt for all residents. The CNA involved in the incident was relatively new and did not secure the safety belt during the bath. Other staff confirmed that the use of the safety belt was not routinely enforced before the fall occurred. The safety belt was available and present in the whirlpool bath rooms, but its use was not consistently implemented.
Failure to Adhere to Enhanced Barrier Precautions and Environmental Cleaning
Penalty
Summary
Staff failed to follow infection prevention practices related to the use of personal protective equipment (PPE) and cleaning of shared equipment for residents on enhanced barrier precautions (EBP). A certified nursing assistant (CNA) was observed transferring multiple residents using a mechanical lift without wearing a gown, despite clear signage and available PPE indicating that gown and glove use was required for residents on EBP. The CNA also failed to clean the lift after each resident use, as required by facility policy and confirmed by interviews with other staff members. Multiple residents on EBP, due to conditions such as wounds, feeding tubes, or multi-drug resistant organisms (MDROs), reported that staff typically wore gloves but not gowns during care and transfers. Additionally, the report documents that urinals without lids were used and left in resident rooms, and that a spill of urine on the floor in one resident's room was not cleaned for approximately two hours. The resident expressed concern about the unaddressed spill, and staff were unaware of the issue until it was brought to their attention. Observations confirmed the presence of urine on the floor, and urinals without lids were noted in the room. The infection preventionist and director of nursing confirmed that urinals should have lids unless otherwise care planned, and that environmental cleanliness is expected. Review of facility policies confirmed that EBP requires gown and glove use during high-contact care activities for residents with wounds, indwelling devices, or MDROs, and that shared equipment such as lifts must be cleaned after each use. The observed and reported failures to adhere to these policies resulted in deficiencies in infection prevention and environmental cleanliness for multiple residents.
Significant Medication Error Due to Incorrect Resident Identification
Penalty
Summary
A certified medication aide (CMA) administered a set of medications intended for one resident to a different resident, resulting in a significant medication error. The error occurred when the CMA prepared medications for a resident who typically ate breakfast in her room but, on this occasion, was found in the dining room. The CMA mistakenly identified another resident as the intended recipient and administered the wrong medications. The error was recognized by the CMA upon reviewing the medication label and was immediately reported to the charge nurse on duty. The resident who received the incorrect medications had a medical history including a left pelvic fracture, paroxysmal atrial fibrillation, type 2 diabetes mellitus with chronic kidney disease, and carotid artery stenosis. After receiving the wrong medications, the resident initially denied symptoms but later experienced nausea, vomiting, and lightheadedness, leading to a request for evaluation at the local emergency department. The incident was documented, and the resident was monitored as per provider instructions. Interviews and record reviews revealed that other staff members who administered medications were not formally educated or re-educated about the incident or the medication administration policy following the error. Several staff members were unaware of the specifics of the incident or could not recall the six rights of medication administration. There was no evidence of formal staff-wide education, monitoring, or auditing of medication administration practices after the event, and the facility's policies did not specify requirements for staff education or follow-up monitoring after such incidents.
Failure to Assess and Update Care Plans for Recliner Safety and Fall Prevention
Penalty
Summary
The facility failed to assess and address the safety needs of three out of five sampled residents who either experienced falls related to recliner use or lacked access to their recliner controls. For one resident with multiple comorbidities including Alzheimer's, osteoarthritis, and congestive heart failure, there were repeated falls, including one from a recliner with the footrest elevated. Despite a high fall risk and changes in condition following hospitalization and hospice admission, the resident's care plan was not updated to reflect new transfer and supervision needs, nor were interventions for safe recliner use documented. The care plan in the electronic medical record remained outdated, and temporary paper care plans were not integrated or accessible to all staff. Another resident with severe cognitive impairment experienced a fall from bed, and although a lift chair/recliner assessment was eventually completed, the care plan did not include safety measures related to recliner use. A third resident, cognitively intact but with Parkinson's and a history of falls, fell while attempting to transfer from a recliner. Interventions identified after the fall, such as monitoring the floor for hazards, were not added to the care plan, and there were no documented interventions for safe recliner use. In all cases, the lack of timely and comprehensive care plan updates contributed to inadequate supervision and accident prevention. Staff interviews revealed inconsistent knowledge and education regarding recliner safety, with CNAs and nurses relying on personal judgment or informal communication rather than standardized protocols. Education on fall prevention was provided, but there was no documented or comprehensive education on recliner safety. Policies required care plans to address all aspects of resident care, including the use of recliners, but these were not consistently followed. Documentation systems did not allow for timely updates to care plans after falls, and staff were unclear on where to find or document recliner safety interventions, leading to gaps in supervision and accident hazard prevention.
Failure to Prevent Accidents Due to Improper Equipment Use and Inadequate Supervision
Penalty
Summary
Staff failed to ensure the safety of three residents who experienced falls related to improper use of equipment. In one instance, a certified nurse aide (CNA) did not secure a safety belt on a bath chair while a resident was seated, resulting in the resident falling forward onto the floor after being moved out of the whirlpool bathtub. The resident sustained a head laceration, nosebleed, and was later found to have cervical fractures. The CNA involved had previously signed an education sheet confirming receipt of training on proper equipment use, including securing safety belts, just three days prior to the incident. However, the CNA stated she was unaware of the requirement to use the seat belt. Following the fall, there were discrepancies in the accounts provided by the registered nurses (RNs) who responded to the incident, and it was unclear whether the resident was appropriately repositioned. The resident was moved with a Hoyer lift to a wheelchair before emergency medical services arrived, despite facility policy indicating that residents with suspected major injuries should not be moved. Additionally, there was no documented neurological evaluation completed after the fall, contrary to facility policy requiring such assessments for falls involving head trauma. In two other incidents, staff failed to use required safety straps during transfers with mechanical lifts. One resident fell from a sit-to-stand lift when the leg straps were not used, resulting in pain and hospital evaluation. Another resident fell from a bath chair after the seatbelt was removed and not replaced, and the chair's wheels were not locked. In both cases, staff were aware of the safety requirements but did not follow them. Care plans were not updated following these incidents as expected. Facility policies and manufacturer instructions required the use of safety belts and locking of wheels during equipment use, but these were not consistently followed.
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.
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