Bethany Home - Brandon

Inspectors wroteBased on a South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure residents were free of significant medication errors for one of one sampled resident (3) who received 2.5 milliliters (mL) of Morphine Sulfate (narcotic) by mouth instead of the ordered dose of 0.25 mL from a certified nursing assistant (CNA)/medication aide (MA) E and experienced decreased oxygen levels, lethargy (abnormal drowsiness or sluggishness that involves low energy, decreased alertness, reduced mental and physical activity), respiratory distress (trouble breathing), and required the use of Narcan (a medication that reverses the effects of opioids).

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 resident privacy and dignity during the administration of personal care treatments for two of two sampled residents (1 and 4) who were administered vaginal cream in the dining room by registered nurse (RN) L where other residents and staff were present.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to report incidents to law enforcement and the ombudsman for two of two sampled residents (1 and 4) when they were administered vaginal medication in the dining room by one of one registered nurse (RN) (L). The facility failed to report to the resident's representative, primary care provider (PCP), law enforcement, and the ombudsman for one of one sampled resident (2) who was verbally abused by one of one certified nursing assistant (CNA) (M) when she provided resident 2 personal care. The facility also failed to report resident 2's incident within a timely manner to the SD DOH. 1. Review of the provider's 2/4/26 SD DOH FRI revealed that residents 1 and 4 had a physician's order for medicated vaginal cream. On 2/4/26 around 7:00 p.m. [...]

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 safety for one of one sampled resident (3) who fell onto the floor and hit his face while being pushed in his wheelchair by certified nursing assistant (CNA) (C), who did not attach and use the wheelchair foot pedals as required when transferring resident 3 to the dining room.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to involve five of thirty (4, 9, 19, 44, and 59) sampled residents' primary care provider (PCP) in the development of the resident's advanced directives according to facility policy, failed to update one of five (44) sampled resident's electronic medical record (EMR) after the resident's code status had changed, failed to include one of five (59) sampled resident's code status on their care plan according to facility policy, and failed to make the resident's updated code status form available to direct care staff in the resident's EMR, which created potential confusion for staff when the most updated form was not available.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to protect three of three sampled residents (16, 37, and 50) and one of one closed sampled resident (101) from alleged verbal abuse and neglect. 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, record review, and policy review, the provider failed to follow their policy and provide the necessary respiratory care and services for four of four sampled residents (4, 8, 10, and 49), resulting in inadequate storage, humidification, and replacement of those devices.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to:*Maintain food safety requirements related to one of one Maple Valley neighborhood pantry room, and one of one Maple Valley kitchenette. *Maintain clean and sanitary conditions for three of three foodservice handwashing sinks in the [NAME] Creek neighborhood.*Implement interventions to supervise and monitor resident refrigerator temperatures to identify any hazards of foodborne illness for two of two observed residents (17 and 24).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to:*Ensure staff members followed proper storage and cleaning procedures for both clean and dirty utility rooms in two of the four facility neighborhoods ([NAME] Creek and [NAME] Wood) to prevent the spread of infection.*Discard products found in one of four resident neighborhoods, such as hand sanitizer and germicidal (germ-killing) wipes, on or before the expiration date which had the potential to affect all people in the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (19), who had a medication pill at his bedside, was assessed for the ability to safely self-administer medications and had a physician's order to self-administer medications according to the provider's policy.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to maintain resident rooms in a clean and well-kept manner, free from damage to walls, for two of two sampled residents (10 and 17) in one of four facility neighborhoods (Cottonwood Court).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure that one of two medication carts was secured while administering medications. Findings Include:1. Observation on 12/17/25 at 11:35 a.m. of licensed practical nurse (LPN) K revealed:*LPN K had walked away from the [NAME] Way medication cart to talk to a resident in the dining area and had left the medication cart unsecured and unattended.*LPN K was not standing at the medication cart and returned to lock the cart at 11:41 a.m.*Several residents were seated in the dining area. 2. Interview on 12/18/25 at 11:00 a.m. with LPN K revealed:*She recalled walking away from the medication cart and not locking it on 12/17/25.*She reported she made a mistake, and she usually locked it when she walked away from it. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure a coffee maker/hot water dispenser in the Maple Valley neighborhood dining area was securely stored to protect the safety of vulnerable residents.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, record review, and policy review, the provider failed to ensure certified nursing assistant (CNA) L had used the whirlpool bath chair safety belt according to the provider's policy during resident 6's bath, CNA K had used the whirlpool bath chair safety belt according to the provider's policy during resident 7's bath, and CNA M had followed resident 4's care plan regarding safe transfers with the mechanical lift equipment. Resident 6 fell out of the bath chair and sustained a pelvic fracture. Resident 7 fell out of the bath chair and sustained multiple fractures to her lower spine, pelvis, and tibia. Resident 4 was transferred using the wrong mechanical lift equipment according to her care plan, and sustained leg bruising and a tibia fracture. [...]

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 the safety of one of one sampled resident (3) who fell out of her wheelchair and received a laceration to the left side of her forehead that required sutures. The fall was related to assistive devices (wheelchair pedals) not being in place to prevent an accident.

Inspectors wroteA. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI)reviews, observation, interview, record review, and policy review, the provider failed to protect the resident's right to be free from verbal and physical abuse by certified nursing assistant (CNA) K while providing assistance with undressing to one of one cognitively impaired sampled resident (1) dependent on staff assistance for activities of daily living (ADLs) and known resistance to care.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, and interview, the provider failed to ensure correct documentation of controlled medications (medications with risk for abuse and addiction) when administered for one of one sampled resident (4). 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, record review, and policy review, the provider failed to: *Ensure that staff were able to verify the chemical sanitation level required to clean the main kitchen surfaces used for the preparation of residents' food. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the main kitchen. *Maintain the dishwasher sanitation rinse cycle temperature at a minimum of 180 degrees Fahrenheit per the manufacturer's manual for two of four kitchenette dishwashers. Failure to ensure that increased the potential risk of foodborne illnesses for 27 of 27 residents (1, 3, 14, 17, 18, 21, 23, 24, 25, 26, 27, 31, 34, 35, 36, 38, 39, 40, 41, 42, 44, 46, 47, 48, 49, 50, and 52) who received meals on dishware cleaned in those two kitchenettes.

Inspectors wroteBased on observation, interview, record review, and job description review the provider failed to ensure the dietitian and dietary director carried out the functions of the food and nutrition services department to ensure the development and implementation of policies and procedures regarding appropriate cleaning, sanitization, and record-keeping were completed in the food and nutrition departments that included the main kitchen and four kitchenettes. Failure to ensure this oversight of the food and nutrition services department increased the potential risk of foodborne illnesses for the entire resident population who received meals that were prepared in the main kitchen and served from the kitchenettes. Findings Include: 1. Refer to F812 2. Interview on 11/08/24 at 12:36 p.m. with dietary director (DD) E revealed: *She was a certified dietary manager. [...]

Inspectors wroteBased on observation and interview, the provider failed to: *Ensure privacy had been maintained during interviews conducted in resident rooms for 13 of 13 (2, 13, 19, 21, 22, 27, 28, 41, 47, 48, 49, 52, and 106) residents with audio and video monitoring devices in their rooms. *Obtain consent for audio and video monitoring use for 6 of 13 (13, 41, 47, 49, 52, and 106) residents with audio and video monitoring devices in their rooms.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to implement an effective grievance process to ensure a resident's right to file grievances included documentation, investigation, and follow-up with the resident and the resident's representative's grievances regarding issues of resident care and quality of life that were important to the resident. That failure had the potential to affect all 52 residents. Specifically, the provider failed to ensure the following: [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint, interview and policy review the provider failed to thoroughly investigate an incident of an alleged certified nursing assistant being intoxicated while at work and allowed her to work the weekend following the incident.

Inspectors wroteBased on observation, interview, record review, and the Centers for Medicaid and Medicare (CMS) Resident Assessment Instrument (RAI) Manual review, the provider failed to ensure the Minimum Data Set (MDS) assessments were coded accurately for two of two residents (23 and 32) who had a seat belt in their wheelchairs.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices had been maintained for the following: *Hand hygiene and glove use for two of three observed resident (16 and 40) dressing changes by two of two registered nurses (RN) (E and L) and one of one licensed practical nurse (LPN) F. *Hand hygiene and glove use during personal care for two of four observed residents (15 and 29) by certified nursing assistant (CNA (N) and LPN D. *Hand hygiene and glove use by one of one RN (L) for two of two observed residents (42 and 44) in the dining room.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure physician's orders and self-administration of medication assessments had been completed for one of three sampled residents (34).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure one of one sampled resident (38) was given advanced notification that she would have been getting a roommate.

Inspectors wrote2. Observation on 7/20/23 at 7:51 a.m. of CNA/MA M revealed she: *Placed 17 grams (gm) of MiraLAX powder into resident 46's glass of cranberry juice. *Placed the glass of cranberry juice onto resident 46's breakfast tray. *Medication for resident 46 had been placed on her breakfast tray. -Medications that had been prepared included: --Allopurinol Tablet 100 milligram (mg) by mouth. --Certa Vite/Antioxidants one tablet by mouth. --Folic Acid 1 mg by mouth. --Lasix 80 mg by mouth. --Meloxicam 15 mg by mouth. --MiraLAX Powder 17 gm/scoop 1 scoop. --Nameda 5 mg by mouth. --Metoprolol 50 mg by mouth. --Senna 8.6 mg tablet 1 tablet by mouth. --Tramadol 50 mg by mouth for moderate pain. ---Pain rating 0/10. -Vitamin C 500 mg by mouth. -Gabapentin 400 mgby mouth. [...]