Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than South Dakota average
South Dakota average: 3.3 deficiencies/year
Deficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 4
Nov 21, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including hospice services, respiratory care, and food safety.
Findings
The facility failed to develop and implement a comprehensive care plan in collaboration with hospice for a resident receiving oxygen and hospice services. Deficiencies were found in respiratory care, including improper maintenance and cleaning of oxygen equipment and inadequate administration of nebulizer treatments. Additionally, food temperatures were not consistently monitored or documented, posing a risk to resident safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, including hospice collaboration and oxygen therapy details. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain cleanliness of oxygen concentrator, tubing, and humidifier, and failed to properly administer nebulizer treatment after determining resident could not self-administer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe food temperatures prior to serving residents, with multiple instances of unlogged and unmonitored food temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure an integrated hospice plan of care was developed, accessible, and updated between the facility and hospice agency. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Physician oxygen order flow rate: 5
Medication Self-Administration Safety Screen score: 14
Food temperature logs missing: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Named in findings related to improper nebulizer treatment administration and oxygen equipment maintenance |
| Director of Nursing B | Director of Nursing | Provided information on hospice care plan expectations and responsibilities |
| Certified Nursing Assistant I | Certified Nursing Assistant | Confirmed resident receiving hospice services and care details |
| Chef H | Chef | Failed to consistently take and log food temperatures during meal service |
| Culinary Services Manager D | Culinary Services Manager | Supervised food service and instructed Chef H to take food temperatures |
| Infection Control RN J | Infection Control Registered Nurse | Provided expectations for oxygen tubing and humidifier maintenance |
| RN C | Registered Nurse | Provided information on oxygen humidifier and distilled water procedures |
| RN L | Registered Nurse | Confirmed absence of distilled water jug in resident's room |
| Chef M | Chef | Observed serving breakfast and noted food temperature procedures |
| Administrator A | Administrator | Acknowledged lack of awareness of food temperature monitoring issues |
Inspection Report
Routine
Deficiencies: 3
Jul 24, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food storage and temperature control standards, specifically focusing on refrigerator temperatures and monitoring practices.
Findings
The facility failed to maintain appropriate refrigerator temperatures for safe food storage, with one refrigerator consistently above the recommended temperature range and missing temperature monitoring documentation. Food items with expired dates and inadequate temperature logs were also found.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| One of seven refrigerators was not set at an appropriate temperature for safe food storage, with temperatures ranging from 43 to 58 degrees instead of the required 35 to 41 degrees. | Level of Harm - Minimal harm or potential for actual harm |
| Two of seven refrigerators were not properly monitored for safe temperature control, with missing documentation for multiple days. | Level of Harm - Minimal harm or potential for actual harm |
| The activity refrigerator contained eggs with no expiration date and expired eggs dated 12/12/22. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Refrigerators monitored: 7
Refrigerators not at appropriate temperature: 1
Refrigerators not properly monitored: 2
Bowls of cherry crisp dessert: 59
Bowls of lettuce salad: 33
Cups of French salad dressing: 36
Ham salad sandwiches: 6
Cakes labeled Hawaiian: 2
Eggs in activity refrigerator: 11
Missing temperature log dates: 12
Missing temperature log dates: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| culinary dining assistant I | Interviewed about refrigerator temperature and usage | |
| culinary manager G | culinary manager | Interviewed about refrigerator temperature issues and repair |
| culinary manager F | culinary manager | Interviewed about refrigerator temperature monitoring and repair |
| activities director E | activities director | Interviewed about activity refrigerator contents and temperature monitoring |
Inspection Report
Routine
Deficiencies: 2
May 12, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, focusing on skin integrity and infection control practices during meal services.
Findings
The facility failed to ensure timely licensed nurse assessments for residents at risk of skin injuries and failed to ensure appropriate use of personal protective equipment (PPE) and hand hygiene by dietary and nursing staff during meal services.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure timely licensed nurse assessments for residents at risk of skin integrity injuries, resulting in minimal harm or potential for actual harm to a few residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure appropriate use of PPE and hand hygiene by nine staff members during meal services, posing minimal harm or potential for actual harm to many residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of residents sampled with skin integrity issues: 2
Number of staff observed with PPE/hand hygiene issues: 9
Dates of Braden scale assessments for resident 56: 4
Dates of Braden scale assessments for resident 75: 6
Dates of nutritional screenings for resident 75: 4
Date of survey completion: May 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN O | Licensed Practical Nurse | Observed completing wound care for residents 56 and 75 |
| Resident Care Coordinator J | Resident Care Coordinator Nurse | In charge of wound care and skin assessment process |
| Director of Nursing B | Director of Nursing | Interviewed regarding skin assessment process and infection control expectations |
| Cook E | Observed with improper glove use and hand hygiene during meal service | |
| Culinary Assistant F | Observed with improper glove use and hand hygiene during meal service | |
| Dietary Manager D | Observed with improper hand hygiene and PPE use during meal service | |
| Cook R | Observed with improper mask use and hand hygiene during meal service | |
| Dietary Aide S | Observed with improper mask use and hand hygiene during meal service | |
| Certified Nurse Assistant Q | Observed with improper glove use and hand hygiene during meal service | |
| Dietary Aide V | Observed with improper mask use and hand hygiene during meal service | |
| Certified Nurse Assistant T | Observed with improper mask use and hand hygiene during meal service | |
| Dietary Aide U | Observed with improper mask use and hand hygiene during meal service |
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