Avantara Pierre

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the staff provided accident prevention interventions and device use according to the resident's care plans (personalized plan that addresses a resident's care needs, goals, and interventions) for one of one sampled resident (29) who needed to be transferred with the use of a full body mechanical lift (a mechanical lift and sling used to lift a person's full body) and sustained a laceration (cut or torn skin) on his right lower leg when certified nursing assistant (CNA) R and contracted travel CNA S assisted the resident to pivot-transfer (when assisted to a standing position, the resident then turns their body to move to another surface) as directed by one of one licensed practical nurse (LPN) K. [...]

Inspectors wroteBased on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure 19 of 19 sampled residents (5, 6, 7, 23, 24, 28, 29, 34, 35, 36, 37, 38, 39, 43, 44, 53, 54, 55, and 57) Minimum Data Set (MDS) assessments (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) were signed by a registered nurse (RN), to verify their MDS assessments were completed, within 14 days after the assessment reference date (ARD) (the specific end date of the observation period used to complete the MDS) and a discharge assessment was completed for one of one sampled discharged resident (31) who was transferred to a hospital and did not return to the facility.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure insulin pens with shortened expiration dates (medications that, after opening, expire before the manufacturer's expiration date) were labeled for two of two sampled residents (10 and 27) insulin pens stored in one of one observed medication cart.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding:The cleaning of a pulse oximeter (a device that clips onto a finger to measure blood oxygen saturation and pulse rate) by one of one licensed practical nurse (LPN) (L) after it was used by one of one sampled resident (44). Hand hygiene (handwashing with soap and water or a hand sanitizer) and glove use by one of one registered nurse (RN) (G) and one of one LPN (L) during medication administration for two of two sampled residents (65 and 44). One of one dietary aide (O) who touched ready to eat foods without the use of gloves. One of one LPN (L) who did not remove personal protective equipment (PPE) after she performed resident cares and before she exited the resident's room. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to protect the resident's right for dignity for one of one sampled resident (17) who was dressed in clothing that had his first name written in black marker on the top of his left pant leg and on the left side of his shirt.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure residents were assessed for their ability to safely self-administer their medications, had a physician's order to self-administer their medications and store those medications in their room, according to the provider's policies for:*One of one sampled resident (54) observed self-administering a medication through a nebulizer (a device that converts liquid medication into an inhaled mist) in her room, who was not assessed for the ability to safely self-administer medications and did not have a physician's order to self-administer that medication.*One of one sampled resident (7) who self-administered her medications had her Symbicort inhaler (a medication to prevent and control inflammation in the lungs and open the airways) and a fluticasone nasal spray (allergy medication) securely stored [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, and interview, the provider failed to protect the resident's rights to be free from verbal, mental, or physical abuse for one of one sampled resident (28) who was verbally abused by one of one certified nurse aide (CNA) Q who called resident 28 a derogatory name, one of one sampled resident (58) who was emotionally and physically abused by one of one contracted travel CNA (Y) who had put her hand inside the residents brief to check if she was incontinent (involuntary urine or bowel leakage) and one of one sampled resident (58) by one of one contracted travel CNA (BB) who was rough while transferring resident 58 and two of two sampled residents (38 and 65) who were emotionally and physically abused by one of one contracted travel CNA (BB) who did not provide appropriate [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow professional standards of nursing by one of one licensed practical nurse (LPN) (L) who did not assess and document one of one sampled resident's (44) pain level before she administered that resident a pain medication, and did not document that pain medication administration on the resident's medication administration record (MAR).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to complete a trauma informed care assessment for two of two sampled residents (5 and 6) with a post-traumatic stress disorder (PTSD-a disorder in which an individual has difficulty recovering after experiencing or witnessing a traumatic event) diagnosis.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure continued behavioral health services to treat a diagnosed mental illness were provided and to identify and implement interventions and effective communication processes with other healthcare entities for one of one sampled resident (10) with depression symptoms and suicidal thoughts.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure:The staff completed and documented controlled medications (medications at risk for abuse and addiction) supply counts for two of two medication carts (East and West), and one of one sampled resident (24) who had one tablet of oxycodone (a controlled pain medication) unaccounted for. The residents were safe from medication errors for one of one sampled resident (66) who was not administered the prescribed dose of antihistamine medication by one of one RN (G).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure an in-room call light (a device activated by a resident to alert staff for assistance) was accessible for one of one sampled resident (2) to use.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interviews, and policy review the provider failed to ensure the on-call physician was notified of complaints of acute pain by one of one sampled resident (1) for determination of treatment. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect for one on one sampled resident (206) who expressed he felt bad that he had been sent to the emergency room (ER) by registered nurse (RN) (N) without being provided personal hygiene after he had been incontinent of loose stool.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to identify and implement pressure ulcer prevention interventions to ensure facility-acquired pressure ulcers had not developed for one of two sampled residents (205) identified at high risk for skin breakdown and dependent on the staff assistance with their activities of daily living (ADL).

Inspectors wroteBased on observation, interview, record review, Voluntary Agreement for Arbitration review, and policy review, the provider failed to ensure 50 of 55 residents (1, 2, 3, 4, 5, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 46, 47, 48, 50, 104, 105, 106, 115, 154, 156, 204, 205, 206, 304, 305) who had entered into an Arbitration Agreement upon admission to the facility were explicitly granted the right to rescind the agreement within 30 calendar days of signing it.

Inspectors wroteBased on observation, interview, record review, testing, and policy review, the provider failed to ensure adequate temperatures for three of three sampled residents (24, 27, and 304) who expressed their rooms were cold and uncomfortable.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure resident care plans reflected the residents' current needs and/or to provide interventions as directed on the care plans for four of twenty sampled residents (3, 34, 205, and 206) as follows: *Interventions were not provided as directed on the care plan for resident 3 who required a fall mat and a call light within her reach. *The care plan did not include interventions to prevent the development of a pressure ulcer for resident 205. *Interventions were not provided as directed on the care plan for resident 206 who required the use of a positioning alarm. *The care plan did not include interventions for lymphedema (condition causing swelling in the arms or legs) wraps for resident 34.

Inspectors wroteBased on observation, interview, record review, and manufacturer's manual review, the provider failed to ensure appropriate infection control practices were followed for: *Enhanced barrier precautions (EBP) (gloves and gown use when providing direct contact care) by two of two certified nursing assistants (CNAs) ( J and S) for one of one sampled resident (205) with a catheter, multidrug-resistant organism (MDRO), and a pressure injury. *Appropriate whirlpool (WP) tub cleaning by two of two CNAs (F and I) in one of two WP tub rooms used for bathing residents. *Maintaining the cleanliness of the laundry room.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (24) who self-administered medications was able to safely self-administer those medications and had a physician's order for self-administration of medications per the provider's policy.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of five sampled residents (28) had received a bed hold notice upon her transfer out of the facility to the emergency room (ER).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the implementation of their smoking policy for one of one sampled resident (11) who smoked and was not assessed for smoking risks and safety.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to: *Maintain the dishwasher, scoop storage drawer, ceiling ventilation fans, ceiling pipes, and floor drains in a clean and sanitary manner to prevent the buildup of crumbs, rust, grime, limescale, and dust. *Ensure one of three reach-in refrigerators was maintained at a temperature below 41 degrees Fahrenheit to prevent the potential growth of foodborne illness-causing bacteria. *Ensure the high-temperature dishwasher reached a minimum temperature of 180 degrees Fahrenheit during the rinse cycle to adequately sanitize dishware. *Properly store two food items that had manufacturer's labels that read refrigerate after opening.

Inspectors wroteBased on observation, interview, record review, policy and procedure and job description the provider failed to ensure the facility was operated and administered by administrator A, in a manner that ensured the safety and overall well-being of all 52 residents in the facility.

Inspectors wroteBased on record review, interview, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure there was current collaborative communication documented and accessible between the provider and hospice agency for three of three sampled residents (24, 33, and 50) receiving hospice services.

Inspectors wroteBased on interview, policy review, and quality assurance and performance improvement (QAPI) plan, the provider failed to ensure performance improvement projects (PIP) had been thoroughly implemented, monitored, and resolved with an effective QAPI process.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure daily staffing information was consistently posted.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to accommodate one of one sampled resident's (33) clothing, activity, and mealtime preferences.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure a Bed Hold Notice form was given to one of one sampled resident (38) prior to transfer to the hospital.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure two of two recently admitted sampled residents (6 and 157) had a baseline care plan that was established within 48 hours of admission and reviewed with the resident, their representative, or their responsible family member.

Inspectors wroteBased on record review, interview, review of a facility-reported incident (FRI), and policy review, the provider failed to ensure one of one closed record sampled resident (258) with a do not resuscitate (DNR) code status who had no pulse or respirations when found by staff had not received cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to: *Monitor and implement bowel management interventions for one of one sampled resident (50) who received hospice services. *Provide appropriate duration and meaningful activities to maintain the well-being for one of one sampled resident (8) with unique psychosocial needs.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident, their representative, physician, and a registered dietitian (RD) had been notified of a significant weight loss for one of one sampled resident (21).

Inspectors wroteBased on observation, interview and policy review, the provider failed to clean one of one sampled resident's (210) nebulizer mask after providing and aerosol treatment.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *Resident medications were secured in one of two medication (med) carts that was left unattended and unlocked by the staff member administering meds. *Resident's personal information was secured on the computer that was sitting on the med cart.

Inspectors wroteBased on observation, interview, and menu review, the provider failed to follow the written menus for seven of seven sampled residents (5, 10, 13, 19, 25, 28, and 50) who received a pureed diet, and one of one sampled resident (9) who received a mechanical soft diet with pureed meats.