Dells Nursing and Rehab Center Inc

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure resident choices regarding bedtime requests were being followed for one of one sampled resident (14).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the staff members followed standard infection prevention practices for:*Storing clean resident use equipment, specifically lift slings, without the slings touching the floor.*Replacing oxygen tubing for one of four sampled residents (35) every 30 days according to the provider's policy.*Personal protective equipment, such as gloves and gowns (PPE), use by one of one observed certified nursing assistant (CNA) D when providing care for one of one sampled resident (15) on enhanced barrier precautions (EBP).

Inspectors wroteBased on record review, interview, job description review, and policy review, the provider failed to ensure blood pressure medications were administered as ordered by the physician for one of one closed resident records (1) by three of three certified medication aides (CMAs) (C, D, and E). These errors in medication administration had the potential to impact the resident's health and well-being. Review of October 2025 closed electronic medical review (EMR) revealed resident 1 was admitted to the facility 10/1/25 and discharged from the facility on 10/27/25 due to an unexpected death. He had primary diagnoses of type 2 diabetes (unstable sugar levels in the blood), orthostatic hypotension (sudden drop in blood pressure when you stand up, which can cause dizziness, lightheadedness, or fainting), and weakness. [...]

Inspectors wroteBased on record review and interview, the provider failed to ensure the proper Medicare notices were filled out completely and were in the required format for three of three sampled residents (9, 37, and 294) prior to their discharge from Medicare Part A skilled services.

Inspectors wroteA. Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of two certified nursing assistants (CNA) (K) wore appropriate personal protective equipment (PPE) while caring for two sampled residents (22 and 32) who were on enhanced barrier precautions (EBP), which is a type of infection control strategy used in nursing homes to reduce the spread of multidrug-resistant organisms. *One of one CNA (N) practiced appropriate infection control techniques during catheter cares for one of one observed resident (22). *Four of four CNAs (L, M, N, and O) were knowledgeable of the provider's revised catheter care policy and had the skills to implement that policy. [...]

Inspectors wroteBased on interview, record review, policy review, and review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), the provider failed to ensure a controlled medication (medication with potential for abuse and addiction) for one of one sampled resident (41) had remained secured and was accounted for. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review the provider failed to report the missing controlled medication (medications with potential for abuse and addiction) had been reported timely to SD DOH.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to: * Implement and monitor care planned approaches for one of one sampled resident (25) identified on admission as having potential for pressure ulcer development prior to the development of a heel pressure ulcer. *Implement, monitor and accurately document skin injuries, and care plan approaches for two of two sampled residents (7 and 33) who acquired pressure ulcers after admission.

Inspectors wroteBased on Payroll Based Journal (PBJ) record review, employee timecard review, staffing schedules, and electronic medical record (EMR) review, the provider failed to submit PBJ data accurately for one of one federal fiscal quarter (Quarter 4, 2024).

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to: *Accurately identify and implement enhanced barrier precautions (EBP) for three of three sampled residents (4, 20, and 24) who had care concerns requiring personal protective equipment (PPE). *Utilize appropriate hand hygiene and gloves during cares by one of one staff (certified nursing assistant (CNA) I with one of one resident (33). *Appropriately maintain and dispose of resident care items in two of two hopper rooms, one of one shower room, and one of one beauty shop.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for: *Three of three sampled residents (4, 9 and 34) who had fallen. *One of one sampled resident (7) who had a facility acquired pressure ulcer. *One of one sampled resident (10) who had a history of urinary tract infections. *One of one sampled resident (11) who developed a facility acquired pressure sore. *One of one sampled resident (29) who had attempted to leave the facility without staff knowledge.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure chemicals had not been stored under sinks in four of four rooms and were secured per their written instructions.

Inspectors wroteBased on record review and interview the provider failed to ensure four sampled residents (11, 29, 33, and 34) had received the wrong medication administered by four of four of staff, registered nurse (RN) (D and F) and certified medication aide (CMA) (O and P).

Inspectors wroteBased on observation, interview, and record review the provider failed to ensure one of one sampled resident (24) had been monitored for consistent weight loss.

Inspectors wroteBased on observation, record review, interview, and policy review the provider failed to adequately implement and monitor an effective antibiotic stewardship program.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review the provider failed to ensure the safety of one of one sampled resident (1) identified at risk for elopement, who had eloped (left the facility without staff knowledge) after staff turned a door alarm off. Failure of staff to ensure the door alarm was reactivated resulted in the resident's elopement and put her at risk for physical injury or serious harm. This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident.