Bethesda of Beresford

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interviews, record review, and policy review, the facility failed to ensure the implementation of policies and procedures for conducting neurological assessments following unwitnessed falls or potential head injuries for three of six sampled residents (1, 2, and 3). Findings Include:1. Review of the provider's 3/3/26 SD DOH FRI revealed on 3/2/26 at 3:35 p.m., resident 1 was found on his fall mattress (padded mat placed directly on the floor) next to his bed by licensed practical nurse (LPN) D. [...]

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interviews, record review, and policy review, the facility did not adequately implement policies and procedures to ensure proper supervision and safe use of required oxygen equipment. This failure resulted in one of one sampled resident (resident 1) being left without prescribed oxygen for one hour and fifty five minutes, identified by him falling out of bed on 3/2/26. When Licensed Practical Nurse (LPN) D assessed the resident, his oxygen saturation level was 60%.

Inspectors wroteBased on observation, interview, record review, policy review, and manufacturer's guideline review, the provider failed to ensure:*Oxygen equipment for two of two sampled residents (3 and 28) who required the use of supplemental oxygen was kept off the floor and appropriately serviced.*Infection control practices had been followed by three of three staff members (registered nurse (RN) J, certified nursing assistant (CNA) K, and CNA L) to minimize the risk of contamination to the oxygen tubing, for one of one sampled resident's (3) who required the use of continuous oxygen.*One of one sampled resident (3) received oxygen as ordered by the physician.*One of one sampled resident's (28) continuous use of oxygen at night was addressed in the resident's care plan.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure:*Documentation was completed consistently for two of two weekly scheduled cleaning tasks of the kitchen.*Temperature monitoring and documentation was completed consistently for one of one coffee machine.*One of one dietary aide (O) had washed her hands before and after serving and touching resident food items to prevent potential contamination.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (40) who eloped (left the facility without staff knowledge).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed by failing to place one of one sampled resident (23) with an open surgical wound on his ear on enhanced barrier precautions (EBP) (gloves and gown use when providing contact care).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure a Bed Hold Notice form was given to four of four sampled residents (1, 2, 3, and 4) prior to transfer to the emergency departmentl.

Inspectors wroteBased on observation, interviews, record review, and policy review, the provider failed to ensure there were sufficient nursing staff to ensure call lights were answered in a reasonable time for five of thirty-five sampled residents (3, 4, 5, 13, and 21).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure necessary food safety guidelines were implemented and followed for appropriate storage and labeling of food and chemical items, appropriate monitoring of the low-temperature dishwasher, and cleaning and sanitary maintenance of one of one kitchen.

Inspectors wroteBased on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff schedule and timecard review, and interview, the provider failed to ensure Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the care of the residents) data was accurately completed before submission to the Center for Medicare and Medicaid Services (CMS) for three of four federal fiscal quarters (Quarter 2, 2023; and Quarter 3, 2023; and Quarter 1, 2024).

Inspectors wroteBased on interview and policy review, the provider failed to ensure that Legionella monitoring and prevention were addressed in the infection control program, which had the potential to affect all 35 residents within the facility.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure a clean and homelike environment was maintained in the following areas: *The activities room. *Resident rooms (1, 4, 5, 9, 13, 17, and 22). *The surfaces of the mechanical lifts. *The hand sanitizer dispensers. *The scale room.

Inspectors wroteBased on interview, observation, admission packet review, policy review, and plan of correction review, the provider failed to: *Make information available on how to file a grievance and the location of the grievance forms readily available to residents and their representatives. *Designate who the grievance official was. Findings Include: 1. Interview with the resident council on 4/24/24 from 1:00 p.m. through 1:35 p.m. revealed: *The residents were not aware of who the grievance official was. *The residents were not aware how to file a grievance or where to find the necessary forms. Observation of the lobby and the public area in the center of the facility around the nursing station on 4/24/24 at 1:40 p.m. and again on 4/25/24 at 2:16 p.m. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure expired medications were not administered to residents, and removed and discarded for nine of thirty bulk medications in two of two medication carts.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the regular safety inspection of bed rails for two of two sampled residents (2 and 7).

Inspectors wroteBased on observation, resident and family interview, call light audit review, and policy review, the provider failed to ensure the resident call light system was functioning for 2 of 13 sampled residents (5 and 13) out of 35 total residents.

Inspectors wroteBased on interview, observation, and review of the resident admission packet, the provider failed to ensure the ombudsman and South Dakota Department of Health (SD DOH) contact information had been posted in a location accessible to all 35 current residents, visitors, and families.

Inspectors wroteBased on interview, observation, and policy review, the provider failed to make the most recent survey results accessible to all residents and their representatives.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to implement a revised advanced directive for one of sixteen sampled residents (32) reviewed for advance directives.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to develop, revise, and implement a comprehensive person-centered care plan that addressed nail care and range of motion for two of fourteen sampled residents (3 and 5). Finding Include: 1. Observation and interview on 4/23/24 at 9:19 a.m. with resident 3 revealed: *There was a picture on the wall with instructions on how to put on a right-hand splint and a schedule for the times that the splint was to have been put on. *Resident 3 indicated she had not worn that splint for a long time. *She rested her right hand in her lap. *When asked to lift her arms she was unable to lift her right arm. *She stated, No, none, when asked about range of motion exercises and if anyone helped her to move her arms. *She indicated that she: -Had been in therapy but was not currently. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure an ongoing restorative nursing program for two of two sampled residents (3 and 5) at risk for a decline in range of motion.

Inspectors wroteBased on review of a South Dakota Department of Health facility incident report, interview, observation, policy review, and document review, the provider failed to develop and implement an effective training and orientation program for five of seven certified nurse assistants (CNAs) (C, E, F, G, and H) that might have contributed to an accident involving a full-body mechanical lift falling on top of one of one sampled resident (1) resulting in bodily injury.

Inspectors wroteBased on interview, observation, 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 35 residents. Specifically, the provider failed to ensure the following: *Information on how to file a grievance or complaint was available to the resident and their representative and posted in a prominent location. [...]

Inspectors wroteBased on interview, and job description review, the provider failed to employ a qualified nutritional professional to serve as the dietary manager.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Four of four sampled residents (1, 5, 19, and 36) scheduled IV controlled medications had been counted and secured under a double lock system. *One of one medication refrigerator had the proper interventions documented for out of range temperatures.

Inspectors wroteBased on observation, interview and policy review, the provider failed to: *Ensure appropriate glove use during the meal preparation and food service by one of one cook (F) during one of one observed meal service. *Maintain the cleanliness of the exhaust fans in one of one walk-in cooler. 1. Observation on 4/3/23 at 4:15 p.m. through 5:15 p.m. during food preparation and meal service with cook F revealed: *She washed her hands with soap and water, dried them, and put on a pair of gloves. *Foods were taken out of the oven and placed on the steam table for the meal service. *Grilled cheese had been on the menu. *There had been a stack of buttered slices of bread on a wooden cutting board on the food preparation table. *A plastic container with slices of cheese was next to the cutting board. *She began to assemble the grilled cheese and placed them on the hot cooktop grill. [...]

Inspectors wroteBased on observation, interview, medical record review, and policy review, the provider failed to assess for the need for bed rails for one of five sampled residents (36).