Deficiencies (last 2 years)
Deficiencies (over 2 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% better than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care plan requirements, specifically focusing on whether resident care plans were updated to accurately reflect residents' abilities to use call lights effectively in the memory care unit.
Findings
The provider failed to ensure that care plans were updated to reflect the residents' abilities to use call lights effectively for five sampled residents with cognitive impairments in the memory care unit. Observations and interviews revealed that call lights were often inaccessible or unused by residents, and care plans did not accurately represent these realities. Staff interviews confirmed that some call lights were intentionally placed out of residents' reach for safety reasons, but this was not documented in care plans.
Deficiencies (1)
Failed to ensure resident care plans were updated to accurately reflect residents' abilities to use call lights effectively for five sampled residents with impaired cognition in the memory care unit.
Report Facts
BIMS scores: 4
BIMS scores: 4
BIMS scores: 9
BIMS scores: 3
BIMS scores: 4
Residents affected: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to ensure a Foley catheter change was completed per physician's order for a sampled resident, and concerns about infection prevention and control practices in one of the facility's shower rooms.
Complaint Details
The visit was complaint-related due to failure to complete a Foley catheter change as ordered. The missed catheter change was not documented, and explanations included staff absence during a COVID outbreak. The complaint was substantiated with findings of missed catheter change and infection control issues.
Findings
The facility failed to complete a scheduled Foley catheter change for resident 93 as ordered, with documentation missing and explanations including staff absence and a COVID outbreak. Additionally, infection control deficiencies were found in a shower room, including unsanitary storage of towels, improper handling and transport of fecal matter during showers, inadequate cleaning and maintenance of foot soak basins, and unlabeled personal hygiene products posing cross-contamination risks.
Deficiencies (2)
Failed to ensure a Foley catheter change was completed per physician's order for resident 93.
Infection control deficiencies in shower room including maintenance of towel storage bin with hard water buildup, lack of sanitary process for removal and transport of bowel movements during showering, inadequate care of multi-resident foot soak basin, and unlabeled personal hygiene products.
Report Facts
Date of missed Foley catheter change: Nov 1, 2023
Date of Foley catheter change completion: Nov 16, 2023
Foley catheter change frequency: 30
Date of survey completion: Nov 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) B | Interviewed regarding missed Foley catheter change and infection control issues. | |
| Registered Nurse (RN) D | Interviewed regarding missed Foley catheter change procedures and EMR system. | |
| Assistant Director of Nursing (ADON) C | Interviewed regarding missed Foley catheter change and infection preventionist duties. | |
| Certified Nursing Assistant (CNA) E | Interviewed regarding shower room cleaning and infection control practices. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to assess compliance with pressure ulcer care standards and to evaluate the facility's interventions to prevent pressure ulcers, specifically focusing on a sampled resident who developed a pressure ulcer.
Findings
The provider failed to implement appropriate interventions to prevent a pressure ulcer from developing in one of two sampled residents. Documentation and interviews revealed delays and gaps in addressing skin alterations and pressure ulcer care, despite policy requirements for assessment and intervention.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for resident 289.
Report Facts
Braden Scale score: 6
Braden Scale score: 17
Pressure ulcer measurement: 10
Pressure ulcer measurement: 5
Pressure ulcer measurement: 8.1
Pressure ulcer measurement: 3.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Observed changing dressing on resident 289's heel and documented skin evaluations |
| RN E | Registered Nurse | Completed nursing admission assessment and admission summary progress note for resident 289 |
| DON B | Director of Nursing | Reported admission bed bath, documented change of condition, and admission summary notes related to resident 289 |
| LPN D | Licensed Practical Nurse | Conducted skin evaluation noting Braden Scale score and skin integrity |
| RAI/MDS Coordinator C | Resident Assessment Instrument/Minimum Data Set Coordinator | Interviewed regarding timing and documentation of skin evaluations and interventions |
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