Firesteel Healthcare Center

Inspectors wroteA. Based on observation, interview, and record review, the provider failed to ensure an environment free from accident hazards for seventeen of seventeen sampled residents (3, 22, 23, 24,29, 43, 48, 70, 74, 78, 83, 84, 86, 92, 102, 106, and 110) who resided within a memory care unit (an area where specialized care is provided in a structured, safe and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, that is secured to minimize unsafe wandering) and had access to the memory care unit exit door key.

Inspectors wroteBased on interview, document review, and policy review, the provider failed to ensure that the resident's grievances were addressed, and documentation reflecting the staff's efforts to resolve those grievances was communicated to the residents and approved as effective resolutions for eight of eight sampled residents (16, 30, 31, 63, 79, 81, 108, and 109) who attended the resident council meeting on 7/29/26 that reported concerns in grievance resolution.

Inspectors wroteBased on interviews, record review, and policy review, the provider failed to ensure the staff responded promptly to four of five sampled residents (31, 46, 105, and 108) who reported concerns about extended call light times.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure sanitizer solutions were tested and documented for one of one main kitchen.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to minimize the risk of residents acquiring and transmitting pneumococcal disease by ensuring that three of five sampled residents (35, 56, and 60) were offered the pneumococcal vaccination.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure resident bathing choices were being followed for one of one sampled residents (105).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure that two of five sampled residents (65 and 73) had a Preadmission Screening and Resident Review (PASRR) level II (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) completed. Findings Include: 1. Review of resident 65's EMR revealed she admitted to the facility on [DATE] and had diagnoses that included depressive disorder, hallucinations, and hoarding disorder. She had a 5/25/23 PASRR Level 1 completed. Her 9/11/23 PASRR Level II screening form determined resident 65 was exempt from a Level II review as the diagnosis of a mental illness was unsubstantiated. On 9/5/24, resident 65 received a new diagnosis of delusional disorders. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one portable oxygen cylinder (a pressurized container that stores and transports compressed or liquid oxygen) was securely transported.

Inspectors wroteBased on observation, document review, and interview, the provider failed to ensure the daily posted nurse staffing information reflected the actual resident census and hours worked by registered nurses (RNs), licensed practical nurses (LPNs), certified medication aides (CMAs), and certified nursing assistants (CNAs) per shift, and was posted in a location visible and accessible to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed standard infection prevention practices regarding enhanced barrier precautions (EBP) (gown and glove use when providing contact care) by one of one contracted travel certified nursing assistant (CNA) (BB) while she changed bed linens for one of one sampled resident (28) who required EBP.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint records, interview, and policy review, the provider failed to report an incident to the SD DOH within the required time frame regarding two of two sampled residents (1 and 6) who had a reportable incident.

Inspectors wroteA. Based on interview, record review, document review, and South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, the provider failed to ensure the staff responded promptly to four of five sampled residents (1,2,4,and 5) who reported they had to wait a long time for their call light to be answered.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), document review, interview, and policy review, the provider failed to secure a controlled medication (medication with risk for abuse and addiction), for one of one sampled resdient (7)'s Dilaudid (an extremely potent schedule II prescription opioid painkiller) that was received at the facility on 3/20/26 was not accounted for the following day on 3/21/26.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the staff provided supervision and accident prevention interventions according to the resident's care plans for one of one sampled resident (2) who fell and sustained multiple facial fractures when left unsupervised in the dining room by a nursing staff member and one of one sampled resident (4) who fell from a mechanical lift when being transferred by certified nursing assistant (CNA) L.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review the provider failed to ensure one of one sampled resident (1) who committed suicide had received the necessary behavioral health services to treat a diagnosed serious mental illness.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure one of one sampled resident (3) had a palm protector (a foam device that fits over the hand to prevent severe finger contractures (curling) from digging into the palm) applied as ordered by the physician for contracture management of his right hand.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *Hand hygiene practices by staff members BB, GG, and HH during two of two dining observations in two of three dining rooms. *Hand hygiene and personal protective equipment (PPE) use by three of three staff observed (L, M, and BB) during personal cares for one of one sampled resident (41), personal cares for one of one sampled resident (33) on contact precautions (which indicated staff should have worn gowns and gloves), and assisting with resident transportation for two of two sampled residents (33 and 85). [...]

Inspectors wroteBased on interview, observation, record review, and policy review, the provider failed to ensure effective pest control for flying ants for one of twenty-six sampled residents (91) who complained of flying ants in his room and ant bites on his back.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow standard food safety practices to ensure: *Prepared foods were covered when stored in one of one walk-in cooler. *The food stored in the walk-in cooler was stored appropriately to prevent cross-contamination. *Potentially hazardous food was prepared, stored, and served at safe food temperatures for one of one observed meal service.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a homelike environment that was free from foul odors for: *The physical therapy gym, the nurse's desk outside the physical therapy gym, and near the rehab dining room. *The area around the nurse's station on the 200-hallway.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to provide bed-hold notices to the resident or the resident's responsible party at the time of transfer to a hospital for four of four sampled residents (33, 52, 66, and 107) who had transferred to the hospital.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure resident care plans were updated to reflect the current needs of three of twenty-six sampled residents (19, 33, and 85), such as resident preferences, skin wound prevention, and PTSD re-traumatizing prevention.

Inspectors wroteBased on record review, interview, resident admission packet review, and policy review, the provider failed to ensure residents or their representatives fully understood the binding arbitration agreement process for two of three sampled residents (66 and 89).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to identify, implement, and document quality assurance and performance improvement (QAPI) plans of action to correct identified infection control deficiencies for three of three months reviewed (January through April 2025) related to hand hygiene and personal protective equipment (PPE) compliance benchmarks.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (31 and 104) were assessed for the ability to safely self-administer medications delivered through nebulizer machines (device that converts liquid medication into an inhalable mist).

Inspectors wroteBased South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview and policy review the provider failed to ensure one of one sampled resident (1) who was identified as an elopement risk on admission had been accounted for when a door alarm activated. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and manufacturer's operator's instructions review the provider failed to ensure *The safety of one of one sampled resident (2) who had to be lowered to the floor while in a sit-to-stand lift (a mechanical lift that requires the person to be able to partially bear weight on at least one leg when assisted from a seated position to a standing position) while being transferred. *While transferring resident 2 from the commode to the recliner two of two certified nurse aides (CNA) (D and L) utilizing the sit-to-stand lift did not adjust the safety strap of the sling. *Six of eight sit-to-stand lifts were used and maintained per the manufacturer's operator instructions.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint intake form, observation, interview, and document review, the provider failed to follow the planned menu for the renal and cardiac therapeutic diets, which had the potential to affect all residents who were prescribed those diets.

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 a residents right to privacy for one of one resident (2) who had a photo taken of her head injury without permission by one of one certified nursing assistant (CNA) (J). 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), record review, interview, and policy review, the provider failed to adequately monitor five of five sampled residents (2, 3, 4, 5, and 6) for neurological changes after they had fallen.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure resident safety by not completing a hot liquid assessment at the time of admission. One of one sampled resident (11) had spilled coffee on herself without injury.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, interview, and policy review, the provider failed to administer physician-ordered antibiotic treatment and monitoring for one of one resident (1) who had an infection and was readmitted to the hospital.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety of one of one sampled resident (1) who had a fall from the full mechanical lift and required hospitalization for injuries the following day. The citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.

Inspectors wroteBased on observation, interview, record review, and resident rights review, the provider failed to ensure staff were available to promptly respond to call lights for seven of seven sampled residents (1, 2, 3, 4, 5, 8, and 9) who used call lights to alert staff of their assistance needs.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint report review, record review, and interview, the provider failed to correctly administer medications as ordered for one of one sampled resident (1) who required hospitalization. Failure to administer medications as ordered may have contributed to resident 1's health condition and need for hospitalization. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on review of provider's 4/17/24 South Dakota Department of Health (SD DOH) facility reported incident (FRI), interviews, record review, and policy review, the provider failed to ensure two of two residents (1 and 2) who smoked were assessed for safety. 1. Review of provider's SD DOH FRI revealed the following: *Resident 1 was at risk for elopement and wore a Wanderguard, (a device worn by the resident that would alarm and alert staff if the resident attempted to open and go through a door). *On 4/16/24 director of nursing (DON) B had notified receptionist F to allow resident 1 to go outside as she would be taking him for a car ride. -Receptionist F had interpreted DON B's comment to allow resident 1 to go outside independently, meant at any time. *On 4/17/24 receptionist F allowed resident 1 to go outside independently. 2. Interview on 4/23/24 at 9:00 a.m. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure appropriate infection control techniques and practices were maintained by one of one certified nursing assistant (CNA) H and one of one housekeeper (G) by not following proper contact precautions when entering one of one sampled resident's (148) room with clostridioides difficile (C. diff).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Two of two convection ovens, two of two ovens, one of one stovetop and two grease trap drawers underneath the stovetop, and one of one flattop grill were maintained and cleaned in a sanitary manner in one of one kitchen. *One of one top of the metal electrical box under the dishwasher was maintained as a cleanable surface. *Food items were appropriately covered, and dated in two of two refrigerators and in one of one walk-in freezer in one of one kitchen and one of one refrigerator in one of one memory care unit.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure: *One of one artificial leather couch and two of two artificial leather chairs were maintained in good repair in one of one memory care unit. *Four of four dining room windows were clean and maintained in good repair in one of one main dining room.