Avera Morningside Heights Care Center

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure adequate supervision was provided to prevent falls for 1 of 3 residents (R2) reviewed for falls. R2 needed increased monitoring for safety due to her fall risk with one-to-one (1:1) supervision which was not provided when the nursing assistant (NA) left R2 alone to go wash their hands. R2 then fell causing harm when R2 obtained a left olecranon (elbow) fracture which needed surgery.

Inspectors wroteBased on interview and document review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program provided supervision for 1 of 1 infection preventionist (IP), to identify a thorough infection control surveillance program included surveillance of all employee illness. QAPI also failed to ensure employee surveillance was appropriately delegated to personnel in employee health (EH) who were not certified in infection control. This had the potential to affect all 74 residents. Refer to F880 and F882Findings include: Review of the current, facilities infection control surveillance for employees identified the facility utilized corporate employee health to track employee illness. The IP failed to have any oversight for employee illness and relied on corporate employee health (EH) to provide facility employee surveillance. [...]

Inspectors wroteBased on interview and document review, the facility failed to have a current, ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that included all staff. This had the potential to affect all 74 residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate oversight of the infection control (IC) program that included employee surveillance of all employees. This had the potential to affect all 74 residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff appropriately assessed, monitored, intervened, and notified the family in a timely manner after a fall for 1 of 1 resident (R1) resulting in a brain bleed and skull fracture causing serious harm and eventual death. The immediate jeopardy (IJ) began 9/15/25 at 10:23 p.m., when the facility failed to ensure staff appropriately assessed, monitored, and intervened after a fall for 1 of 1 resident (R1) who had an unwitnessed fall with visible facial bruising and facial structure abnormalities, that resulted in delayed medical examination by a physician and early treatment. R1 was finally transferred to the emergency room 9 hours post fall to the local hospital, where a brain bleed and skull fracture were discovered resulting in serious harm and eventual death. [...]

Inspectors wroteR32 R32's October 2024, Medication Administration Record (MAR) identified R32 was to be administered erythromycin 0.5% ophthalmic eye ointment. Observation and interview on 10/30/24 at 8:12 a.m., with licensed practical nurse (LPN)-A during medication administration identified she put on gloves (donned) gloves, opened the drawer of the medication cart, removed R32's blister packs of medication, and placed them into a medication cup. With her gloved hands, LPN-A placed the blister packs into the drawer, opened another drawer and took out a tube that contained erythromycin (antibiotic) eye ointment. LPN-A then closed the drawer, locked the medication cart, and walked down to R32's room. LPN-A knocked on the door, opened it, sat the medication on the overbed table, and administered the eye ointment. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate infection control technique was followed during 1 of 1 meal service. This had the potential to affect all 20 residents residing on the Gardens unit.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure hand hygiene was provided to 1 of 1 resident (R21) prior to mealtime and during morning cares and required staff assistance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to identify and implement interventions to prevent new pressure ulcer (PU) development for 1 of 1 resident (R61) who was at risk for PU upon admission. This caused actual harm when the facility failed to identify interventions to prevent new PU's to R61's heels and hip.

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to have evidence of a Performance Improvement Project (PIP) which identified facility specific high risk or problem-prone areas, develop an action plan to correct the identified areas of concern, and to ensure the committee participated in the development and oversight of the systems. This had the potential to affect the quality of care and quality of life for all 72 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the hot steam table was separated from the resident's area in 1 of 3 kitchenettes observed (Gardens resident dining area) placing residents at risk for potential burns.

Inspectors wroteBased on observation and interview the facility failed to ensure the steam table where resident meals were served had a sneeze guard to protect food from being contaminated by nearby staff. This had the potential to effect all 12 residents who ate in the Gardens dining area.

Inspectors wroteBased on observation, interview and document review the facility failed to follow manufacture's instructions for cleaning and disinfecting 2 of 2 Master Care Air Jetted tubs located on the First floor. This had the potential to affect 24 of 34 residents, ( R1, R3, R4, R5, R8, R11, R12, R13, R15, R17, R18, R21, R23, R24, R27, R33, R35, R36, R37, R41, R46, R47, R51, and R60) who utilized the two tubs. The facility also failed to ensure staff followed policy and procedure for donning and doffing personal protective equipment (PPE) following use with a resident who was on precautions and failed to sanitize a Hoyer lift following use with a resident on contact precautions.

Inspectors wroteBased on interview and document review, the facility failed to perform antibiotic stewardship to include antibiotic use protocols and a system to monitor antibiotic usage and determine if the prescribed antibiotics resolved the identified infectious process for 22 of 72 sampled residents (R2, R6, R7, R10, R11, R13, R21, R22, R28, R36, R37, R38, R43, R47, R53, R61, R167, R267, R268, R269, R270, and R271) identified in the facility's infection control surveillance. This had the potential to affect all 72 residents who were or may receive antibiotic therapy in the future.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status and needs for 1 of 1 resident (R48) reviewed for elopement.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident cardiopulmonary Resuscitation(CPR) orders were consistent throughout the medical record for 1 of 16 residents reviewed (R3) and ensure staff were knowledgeable as to where to identify documents in order to prevent discrepancies.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R16) received assistance with hand splints to prevent worsening of contractures.