Avantara Saint Cloud

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that the physician was promptly notified of a change in condition for review and recommendations to ensure prompt assessment and treatment for one of one sampled resident (1) identified to be vomiting and with increased weakness, by one of one registered nurse (RN) E. This failure resulted in resident 1 being transferred to the emergency room (ER) for evaluation and subsequent hospitalization. The provider also failed to notify the resident's first emergency contact of the resident's change in condition.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that physician orders for an antibiotic, a medicated nebulizer (a device that converts liquid medication into an inhalable mist) treatment, and cough syrup were transcribed and initiated by one of one registered nurse (RN) F which resulted in a delay of treatment for one of one sampled resident 2, which potentially contributed to his transfer to the emergency room (ER). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure medications and biologicals were labeled, stored, and discarded regarding:*Expired medications and supplies were discarded in two of two observed storage rooms.*One of one medication cart that was left unattended and unlocked by one of one registered nurse (RN) (I) in the dining room, where residents, unauthorized staff, and visitors could access it. *Medications with shortened expiration dates (medications that expire in a timeframe after opening that is prior to the manufacturer's expiration date) stored in one of one medication carts were labeled when they were opened.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *One of one observed certified nursing assistant (F) who assisted three of three sampled residents (62, 56, and 22) with eating during one of one observed noon meal service. *One of one observed licensced practical nurse (E) who assisted two of two sampled residents (1 and 38) with eating during one of one noon meal service.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure staff followed professional standards of practice regarding the respiratory care for one of one sampled resident (78), who received oxygen when he previously resided at a hospital from [DATE] through his admission to the provider's facility on 1/21/26, when staff failed to clarify and provide the resident's oxygen needs.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the facility failed to protect the resident's right to be free from neglect by having failed to ensure the safety of one of one sampled resident (1) who sustained femur (thigh bone) fractures after being transferred from her wheelchair to her bed by two of two certified nursing assistants (D and E) who did not follow her care plan or the facility's policy for gait belt (a waist strap gripped as support for safe mobility and transfers) use; and by one of one licensed practical nurse (LPN) C who did not perform a physical assessment of resident 1 after being notified by CNA D and CNA E of the transfer. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake, interview, report review, facility assessment review, and policy review, the provider failed to ensure daily posted staffing information was updated to reflect the actual number of nursing staff and the hours those staff had worked on three of four overnight shifts reviewed.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, observation, and interview, the provider failed to protect the residents' right to be free from physical abuse for two of two sampled cognitively impaired residents (1 and 2) by one of one certified nursing assistant (CNA) (C). This citation is considered past non?compliance based on a review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on observation, interview, job description review, and policy review, the provider failed to ensure: *The kitchen and dishroom were maintained in a clean and functional manner. *Food items placed on trays and delivered to residents to eat in their rooms (room trays) were kept covered during transport until they were delivered to their rooms. *Insulated dinner plate covers were handled in a sanitary manner.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to maintain the environment and resident use items in a clean and odor-free condition for: *A soiled utility room located directly across from the entrance into the secured unit. *Two of sixteen sampled resident rooms (103 and 108) located in the 100 hallway. *One of one laundry room. *One of one clean utility room located in the secured unit. *A urine-soaked chair from one of one sampled resident's (58) room.

Inspectors wroteBased on observation, interview, South Dakota (SD) State Long-Term Care Ombudsman Program handbook review, and policy review, the provider failed to ensure: *Window coverings in 12 of 14 resident rooms (301, 302, 303, 304, 305, 306, 307, 309, 311, 312, 314, and 316) located in the 300 Hall had protected those residents' right to privacy. *Window coverings in 5 of 9 resident rooms (105, 107, 111, 113, and 115) located in the 100 hall had protected those residents' right to privacy. *One of 14 residents' (2) electronic medical records (EMR) were secured and not accessible to other residents, staff, or the public. *One of two medication carts were locked and medications were not accessible to other residents, staff, and the public by one of one registered nurse (RN) J in the Main dining room during the noon medication pass.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to maintain a clean and homelike environment for: *8 of 14 resident rooms (301, 303, 304, 309, 311, 312, 314, and 316) on the 300 hallway. *5 of 22 resident rooms (202, 204, 206, 207 and 209) on the 200 hallway. *6 of 23 resident rooms (103, 104, 108, 110, 115, and 117) on the 100 hallway.

Inspectors wroteBased on observation, interview, record review, policy review, and South Dakota (SD) State Long-Term Care Ombudsman Program handbook review, the provider failed to ensure: *One of one sampled resident (31) had received diabetic fingernail care to maintain a dignified appearance. *One of one sampled resident (8) was dressed in a dignified manner.

Inspectors wroteBased on observation, interview, record review, and job description review, the provider failed to ensure physician's orders were followed for the use of: *TED Hose (thromboembolic deterrent compression stockings used by non-ambulatory residents) by one of one sampled resident (39). *Redi-Wraps (adjustable compression wrap) by one of one sampled resident (8). *Gradual compression stockings (compression stockings that are tightest around the ankle and gradually loosen up the leg) by one of one sampled resident (65).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (19) who had a history of moisture-associated skin damage (MASD) and had a current pressure ulcer (PU) had physician-ordered interventions implemented to promote healing.

Inspectors wroteBased on observation, interview, record review, review of the South Dakota Board of Nursing website, and policy review, the provider failed to ensure professional standards of care were followed for: *Medication administration practices by one of one licensed practical nurse (LPN) (H) for three of three observed residents (2, 7, 17, and 22). *Ensuring physician's orders for Tylenol were written for two-325 miligram (mg) tablets for three of three sampled residents (8, 33, and 65) to eliminate the need for a dose calculation by one of one unlicensed medication aide (UMA) (I). *Insulin administration by one of one LPN (F) for one of one sampled resident (25). *deceased note was documented in the medical record of one of one sample resident (71). *A follow-up appintment was made for one of one sampled resident (49) to receive a new lower partial denture.

Inspectors wroteBased on observation, interviews, record review, and policy review the provider failed to assess, document and provide interventions per their policy for one of one sampled resident (49) who had suicidal ideations. 1. Observation and interview on 10/24/23 at 2:42 p.m. with resident 49 revealed: *His door was closed. *CNA J knocked on resident 49's door. -Resident 49 opened the door and came into the hallway. *Resident 49 was smiling and answered basic questions before returning to his room. Interview on 10/24/23 at 2:50 p.m. with CNA J revealed resident 49 often barricaded his door from the inside. Review of resident 49's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: -Post-Traumatic Stress Disorder. -Alcohol-induced persisting dementia. -Alzheimer's Disease. -Anxiety. -Obstructive sleep apnea. -Hearing loss. [...]