Fountain Springs Healthcare

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of a resident regarding the use of devices according to the care plan when one of one sampled resident (1) who needed to be transferred with a stand aid lift (a mechanical device used to assist from a seated to a standing position) while using a gait belt and pivot transfer (after assisting a resident to a standing position without a lift, the resident then turns their body to move to another surface). 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, record review, interview, and policy review, the provider failed to ensure:*Proper infection control practices had been followed for the cleaning and storage of nebulizer masks (a mask worn when using a nebulizer machine that converts liquid medication into an inhalable mist) for two of two sampled residents (21 and 79).*Proper infection control practices had been followed for cleaning of the Continuous Positive Airway Pressure (CPAP) machine ( a device that uses air pressure to keep breathing airways open) for one of one sampled resident (16).*Proper infection control practice had been followed for cleaning and storage of oxygen equipment for three of three residents (16, 67, and 97) who required the use of oxygen.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure:One of one observed certified medication aide (CMA) (F) had followed a physician's order for the administration of one of one sampled resident's (55) blood pressure medication. One of one observed registered nurse (RN) (E) had not split one of one sampled resident's (77) antipsychotic medication without first confirming this was an acceptable and safe practice. One of one observed RN (E) had documented the destruction of one of one sampled resident's (77) antipsychotic medication. One of one observed RN (E) had not documented that she had administered medications that were administered by one of one CMA (G). One of one observed CMA (G) had not administered medications to one of one sampled resident (77) that were prepared by one of one RN (E). [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure:The Emergency Kit (E-Kit, a secured storage container stocked with specific medications that were used for a resident during an unplanned medical emergency) controlled medications (medications regulated by the government due to their potential for abuse or addiction) had been routinely accounted for. Narcotic administration and narcotic counts for two of three sampled residents (31 and 98) were accurately documented, and any discrepancies in those counts had been identified and reconciled. The destruction of one of one sampled resident's medication (98) was documented and accurately accounted for after it was not administered.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (79 and 84) were 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 record review, interview, and policy review, the facility failed to ensure accurate documentation of the resident's wishes involving their advance directives (a legal document that expresses a person's health care wishes if they become unable to speak for themselves)/code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) for one of one sampled resident (5).

Inspectors wroteBased on record review, interview, policy review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 October 2024, the provider failed to ensure that one of one sampled residents (13) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the area of active diagnoses.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure that one of one sampled resident (13), who had a categorical convalescent period of 100 days (referring to a person recovering from an illness or operation) preadmission screening and resident review (PASRR) (a federally mandated program that screens individuals to ensure that those with a serious mental illness (SMI) or an intellectual or developmental disability (ID/DD) receive appropriate care in the correct setting), was rescreened when resident 13 stayed in the facility for over 100 days.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review the provider failed to complete a baseline care plan for one of one recently admitted sampled resident (38) within 48 hours of her admission to the facility.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, and record review, the provider failed to ensure:*One of one sampled resident's (77) Wander Guard was not removed by one of one licensed practical nurse (LPN) R.*The presence and function of one of one sampled resident's (77) Wander Guard was accurately documented by two of two LPNs (M and R) and one of one registered nurse (RN) (Q).*Transport driver P securely fastened the four safety hooks to the resident's (60) wheelchair in one of three facility-operated buses before the transport driver started transporting the resident to another location. Failure to ensure the safety hooks were securely fastened potentially placed the resident at risk for harm or injury. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure that allegations of abuse for one of one resident (1) were promptly investigated and reported. Failure to promptly investigate and report the allegation may have put all residents at risk for potential abuse. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure: *A physician-ordered diet order was followed for one of one sampled resident (1). *Appropriate and timely emergency medical intervention was initiated for one of one sampled resident (1) who choked during a meal service. On 8/15/24 at 9:00 a.m., an Immediate Jeopardy was identified for a FRI related to the quality of resident care and treatment that occurred on 7/24/24. The investigation revealed verbal and written education initiated on 7/24/24 removed the immediacy. [...]

Inspectors wroteBased on a facility reported incident (FRI) review, observation, interview, record review, and manufacture operator's instruction review, past noncompliance was confirmed for an incident occurring on 4/29/24.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed by: *One of one licensed practical nurse (LPN) D during three of three dressing changes for one of one sampled resident (63) . *Two of two certified nursing aides (CNA) (E and F) during catheter care for one of two sampled residents (129).

Inspectors wroteBased on observation, interview, record review, review of the facility-reported incident (FRI), and policy review, the provider failed to maintain a secured environment for one of one sampled resident (1) with a history of wandering and severe cognitive impairment who had eloped on 12/25/23 outdoors and into a fenced courtyard approximately 100-150 feet from the door he had exited from.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were maintained for the following: *Proper hand hygiene for one of one certified nurse aide (CNA) I during a transition in personal care between two of two randomly observed residents (63 and 67). *Use of an uncleanable foam wedge by one of one sampled resident (21). *Proper gown use for one of one licensed practical nurse (G) (LPN) during wound care and two of two CNAs (H and I) during personal care for one of one sampled resident (21). *Cleaning of one of one mechanical lift by one of one observed CNA (L). *Routine cleaning of four of four medication carts.

Inspectors wroteA. Based on observation, interview, maintenance logbook review, and policy review, the provider failed to ensure privacy had been maintained for: *One of one sampled resident (21) whose window blind had been left open during her personal care. *Two of two random residents' rooms (111 and 349 B) with window blinds that were missing vertical slats and unable to have been completely closed. *One of one random resident's room (340 B) that had no window covering.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure appropriate procedural techniques had been followed for: *One of one sampled resident (15) by one of one resident care manager/registered nurse (RCM/RN) (E) during the removal of her midline intravenous (IV) catheter used for medication administration. *One of one licensed practical nurse (LPN) G during inhaler medication administration for one of one sampled resident (38).