Avera Mother Joseph Manor Retirement Community

Inspectors wroteBased on observation, document review, and interview, the provider failed to ensure the posted nurse staffing information included the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift, and that the form was posted daily.

Inspectors wroteBased on observation, document review, interview, and policy review, the provider failed to:*Ensure appropriate hand hygiene was performed by six dietary staff (K, T, U, BB, and CC) to meet professional food cleanliness standards.*Maintain three of three dishwashers and three of three sanitation solution containers in a manner that met professional food service sanitation standards.

Inspectors wroteBased on interview and policy review, the provider failed to implement an effective grievance process to ensure residents' satisfaction with the resolution of voiced grievances for:*Two of two sampled residents (55 and 76) regarding long call light response times and noise at night.*One of one sampled resident (89) regarding long call light response times and receiving medications late.*One of one sampled resident (67) regarding cold food and menu choices.*One of one sampled resident (90) regarding lost hearing aides.

Inspectors wroteBased on interview, observation, record review, call light report review, and policy review the provider failed to ensure prompt staff response to resident call lights for seven of seven residents (30, 34, 45, 55, 71, 73, and 76 ) who complained of slow responses to call lights.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to protect the resident's rights and ensure a resident's advance directive code status (an individual's desire to be resuscitated with cardiopulmonary resuscitation (CPR), specific limited interventions, or not resuscitated (DNR) if their heart stopped) wishes were identified accurately on the physician's orders and the care plans for one of 32 sampled resident (55).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed respiratory professional standards for:*The clean storage of nasal cannulas (flexible tubing with prongs that delivers oxygen through the nose) for three of three sampled residents (5, 50, and 90) who used them.*The cleaning and storage of nebulizer masks (a mask worn when using a nebulizer machine that converts liquid medication into an inhalable mist) for three of three observed sampled residents (5, 42, and 63) who used them.*The cleaning of Continuous Positive Airway Pressure (CPAP) machines (a device that uses air pressure to keep breathing airways open) for two of two observed sampled resident (5 and 90) who had CPAP machines in their rooms.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure standard infection prevention practices were followed by:*Two of two certified nursing assistants (CNA) ( R and Y) and 1 of 1 registered nurses (RN) (Z) removed their gloves prior to entering the hallway.*Two of two CNAs (R and Y) and one of one RN (Z) performed hand hygiene (handwashing) prior to the application and after the removal of gloves for one of one residents (51).*One of one CNA (R) who used a phone with soiled gloves while in one of one sampled resident's (51) room who was on enhanced barrier precautions (glove and gown use) after assisting that resident with personal hygiene.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, and interview, the provider failed to withhold cardiopulmonary resuscitation (CPR) for one of one resident (1) with a do not resuscitate/do not intubate (DNR/DNI) code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) who experienced a choking episode, choked, and had no pulse or respirations after her airway was cleared.

Inspectors wroteBased on South Dakota of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure professional standards of nursing practice were followed by licensed practical nurse (LPN) H who had failed to document and communicate one of one sampled resident (1) newly observed wound to the physician to initiate timely evaluation and treatment. Failure to document and communicate the new wound delayed wound treatment and may have delayed the healing of that wound. This citation is considered past non-compliance based on the review of the corrective actions the provider implemented immediately after they became aware of the wound and the provider's internal investigation.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from his wheelchair while being pushed by facility staff. Failure to use wheelchair pedals may have contributed to resident 1's fall. This citation is considered past noncompliance based on the corrective actions the provider implemented immediately after the incident.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure: *Two of two sampled residents (38 and 68) home narcotic medications had been reconciled and accounted for. *Three of five residents (8, 29, and 55) did not receive expired medications.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to: *Ensure environmental precautions were in place to prevent harm to one of one sampled resident (37) who received a burn to her left ankle from a heat register in her room after her bed had been moved. *Implement timely and appropriate bowel management interventions for one of one sampled resident (128) who had been receiving hospice services.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure ongoing and timely skin assessments were conducted and documented by a licensed nurse prior to the development of pressure ulcers for two of two sampled residents (20, and 58).

Inspectors wroteBased on observations, interviews, cleaning checklist review, and policy review, the provider failed to: *Clean six of six hood vent covers on a regular schedule to prevent the buildup of dust. *Properly clean and delime one of one dishwasher to prevent limescale buildup. *Ensure one of one vent duct above the dishwasher remained free from dust buildup. *Maintain the following food preparation equipment in a clean and sanitary manner that was free from burnt food particles and grease buildup: -One of one fryer. -One of one flattop grill grease trap drawer. -Three of three conventional ovens. -Two of two convection ovens. *Properly label food items and discard expired foods in two of two foodservice kitchenette freezer/refrigerator units and two of two resident's communal freezer/refrigerator units. 1. Observation on 3/21/23 from 8:22 a.m. to 8:50 a.m. in the kitchen revealed: [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Routine cleaning and disinfection of high touch surfaces in the semi-private room shared by one of one COVID-19 positive resident (48) and her roommate (71). *Proper handling and disposal of mealtime utensils used by one of one COVID-19 positive resident (48). *Appropriate glove use and hand hygiene had been performed during morning personal care for one of one sampled resident (31). *Appropriate cleaning and sanitizing of the E-Z stand mechanical lift and the body sling between two of two residents (12 and 31).

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure: *One of one sampled resident's (10) medication had been labeled and securely stored. *Proper medication self-administration practices had been followed for one of one sampled resident (10).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure an integrated plan of care had been developed for one of one sampled resident (128) receiving hospice services.