Avera Prince of Peace

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure that the transfer of one of one sampled resident (1) to another long-term care facility met the requirements. Specifically, the facility did not:*Provide documentation that the transfer was necessary for the resident's welfare and that the facility could no longer meet the resident's needs.*Demonstrate that the transfer was appropriate because the resident's health had improved sufficiently.*Provide evidence that the health and safety of individuals in the facility were endangered.*Document that the resident had failed to pay for their stay after receiving appropriate notice.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to provide a written notice to the resident, the resident's representative, and the Office of the State Long-Term Care Ombudsman at least 30 days prior to the planned transfer for one of one sampled resident (1) who was discharged to another long-term care facility.

Inspectors wroteBased on resident council meeting, resident council meeting minutes review, and interview, the provider failed to provide resource information and prompt resolution to residents' requests and concerns voiced in resident council meetings that were to the residents' satisfaction.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure resident personal and medical records remained secure and confidential in four of six observed resident neighborhoods (Bluegrass Way, Platinum Ridge, Boulder Creek, and Arrowhead Trail).

Inspectors wroteBased on resident council meeting response, subsequent individual interviews, resident complaint/grievance reports, and policy review the provider failed to ensure residents were kept free from neglect as it related to ten of twelve residents who attended resident council on 8/21/25, in addition to 11 of 11 sampled residents (2, 44, 51, 61, 66, 73, 77, 79, 91, 108, and 126) who communicated complaints of long staff response times to call lights, which left the residents feeling humiliated, fearful, and in pain.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Insulins with shortened expiration dates were dated properly for five of five random residents (27, 44, 60, 75, 76).*Medical supplies, such as glucose testing strips, sterile water, distilled water, and formula, were dated properly for seven of seven residents (4, 9, 27, 44, 63, 75, 119) in two of five observed units. *Medications were not accessible by unnecessary persons throughout the Rehab, Arrowhead Trail, Boulder Creek, Bluegrass Way, and Platinum Ridge units. *Proper medication administration for two of two residents (63 and 119) without a self-administration physician's order or safety assessment completed.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices by not having ensured proper glove use and hand hygiene was performed during two of two observed resident meal services in two of three neighborhood dining rooms by three of three servers (O, S, and U), and five of five certified medication aides (P, Q, R, V, and W).

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the staff had followed standard infection control practices to decrease the risk of infection to other residents, staff, and visitors for ten of ten sampled residents (4, 9, 20, 33, 49, 75, 76, 119,126, and 129) on enhanced barrier precautions by eight of eight observed staff members (certified medication aides (CMAs) M, FF, GG,NN licensed practical nurse (LPN)s HH, LL, MM, and registered nurse (RN) G) according to the provider's policy.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (129) who received psychotropic medications (any medication that affects brain activities associated with mental processes and behavior) had an attempted gradual dose reduction (systemic dose reduction over time to determine if the condition could be managed with a lower dose or discontinuation of the medication) (GDR) or a documented rationale to support that a GDR for those medications was clinically contraindicated (not appropriate based on the resident's condition, potential risks, or adverse effects) according to the provider's policy.

Inspectors wroteBased on interview, record review, and policy review the provider failed to ensure one of one residents (15) preadmission screening and resident review (PASRR) assessment level II (in-depth evaluation of a resident's needs, recommended services, and determination of what type of setting was appropriate for her care) was coded accurately on the Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs).

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure a medication error rate below 5%. Two of twenty-seven observed medications administered by certified medication aide (CMA) K and FF were completed with an error, which resulted in a 7.41% medication error rate.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the facility failed to ensure the safe use of a mechanical lift (a mechanical lift and sling used to lift a person's full body) by not having assessed the resident for the appropriate lift sling size to have used for one of one sampled resident (2) who fell from the sling and sustained multiple fractures. 1. [...]

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure a thorough investigation was completed for one of one sampled resident (3) who fell in her bathroom and sustained a femoral (thigh bone) fracture.

Inspectors wrote2. Observation on 3/11/24 at 3:30 p.m. with resident 21 revealed that she was seated in her wheelchair and self-propelling herself in the hallway. After greeting her, she made eye contact and smiled but did not answer any questions. Interview on 3/14/24 at 12:18 p.m. with agency certified nursing assistant(CNA)/medication aide(MA) M regarding resident 21 revealed: *Today was her first time working with the resident. *At the beginning of the shift, the other staff stated, I might have a little trouble with her. *The resident was a little combative and resistive to care, she requested help from another CNA to get the resident up and dressed for the day. *That morning, the resident refused her medications and had not eaten her breakfast because she was tired, but after a while, she reapproached the resident who then took her medications. [...]

Inspectors wroteBased on observation, record review, interview, and policy review the provider failed to follow the pressure ulcer prevention interventions documented in the care plan for one of one sampled resident (3) who was at risk for developing pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure their policies had been followed for monitoring and documenting food temperatures prior to meal services to ensure safe food temperatures in three of four kitchenettes.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure proper infection prevention and control practices for the following: *One of one RN coordinator (I) exited resident 80's airborne isolation room and had not performed hand hygiene after removing his N95 mask and prior to putting on a surgical mask. *Glove use and hand hygiene for one of one registered nurse (RN) (J) and one of one licensed practical nurse (LPN) (H) while providing personal care for one of one sampled resident (48) who was on contact precautions for Klebsiella pneumoniae (a gram-negative bacteria) in her urine. *Handling a Foley catheter bag by one of one LPN (H) while transferring and providing cares for one of one sampled resident (48) who was on contact precautions for Klebsiella pneumoniae (a gram-negative bacteria) in her urine.