Good Samaritan Society Canistota

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (7) with risk for developing skin wounds caused by prolonged pressure and expressed discomfort in areas of irritated skin around her suprapubic catheter (a flexible tubing surgically placed through the abdomen into the bladder to drain urine) insertion site and in her abdominal fold was assessed for irritation and her physician was notified of those skin conditions to determine and order treatment to promote healing and prevent those areas from worsening or developing into pressure wounds.

Inspectors wroteBased on record review and interview, the provider failed to ensure the code status (emergent treatment a person wishes to receive if their heart or breathing would stop) for thirteen of sixteen sampled residents (1, 3, 5, 6, 9, 23, 26, 40,42, 44, 46, 51, and 58) wishes were determined and accurately documented in the residents' electronic medical records (EMR) at the time of their admission to the facility and one of one sampled resident (46) with discrepancies in his documented code status.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the staff followed standard food safety and sanitation practices in the kitchen and food storage areas where residents' food was stored, prepared, and served.

Inspectors wroteBased on interview, observation, and policy review, the provider failed to ensure the staff followed infection prevention practices regarding the disinfection of one of one whirlpool by one of one observed certified nursing assistant (CNA) (I), and the prompt cleaning of two of two sampled residents' (6 and 44) bedroom floors observed with bowel movement (BM) on them.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure two of two sampled residents'(42 and 46) 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) assessments were accurately coded regarding Pre-admission Screening and Resident Reviews (PASRR), used to screen residents for serious mental health, intellectual disabilities, or developmental disabilities to ensure appropriate placement and specialized services, and Level I PASRRs.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (1 and 46) with diagnosed anxiety, behaviors, psychosis, and mood disturbances had a Preadmission Screening and Resident Review (PASRR) reviewed for accuracy to ensure the resident were evaluated for mental health care needs.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure the safe use of devices by two of two certified nursing assistants (CNA) (H and K) observed transferring a resident to and from her wheelchair and her mattress without a gait belt (a waist strap gripped as support for safe mobility and transfers) for one of one sampled resident (11) with Huntington's disease (a progressive genetic disorder that causes the breakdown of nerve cells in the brain and involuntary movements) who needed to be transferred with the assistance of two staff members and the use of a gait belt. That failure put the resident at risk for falling and injury. 1. Observation and Interview on 3/17/26 at 3:33 p.m. [...]

Inspectors wroteBased on interview, record review, and policy review the provider failed to provide bed-hod notices to residents and/or their representatives regarding transfers to the hospital on two of three occasions for two of two sampled residents (9 and 46).

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure: *Necessary food safety guidelines were followed for appropriate storage of resident food items. *Proper cleaning procedures were followed for dishes used to store, prepare, and serve residents' food in one of one main kitchen.

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure one of one sampled resident (42) had reviewed and was provided a summary of her baseline care plan within forty eight hours of admission.

Inspectors wroteBased on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to accommodate one of one sampled resident's (2) snack time preferences.

Inspectors wroteBased on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the care plan was revised to reflect the current snack preferences for one of one sampled resident (2).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, Roam Alert (door alarm) log review, and video 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 rearmed resulted in the resident's elopement and put him at risk for physical injury or serious harm. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on interview, record review, and policy review the provider failed to ensure one of one resident (23) who had a mental illness had a Preadmission Screening and Resident Review (PASARR) Level II completed timely. Review of resident 23's medical record revealed her: *admission date was 9/15/20. *Diagnosis included bipolar and an 8/25/21 schizoaffective disorder. *7/25/23 Brief Interview of Mental Status was a 15, that score meant she was cognitively intact. *Her care plan included: -She preferred to remain in her room. -She had disruptive behaviors including screaming and cursing at other people. -She had a private room due to the above. -Mental health services were provided to her by a behavioral health agency. Review of resident 23's admission PASARR revealed it: *Was completed on 8/24/20. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Treatment and documentation had been completed for one of one sampled resident (37) according to the provider's polcy who had skin tears. *Two scheduled nebulized medications ordered by the physician for one of one sampled resident (37) were not obtained from the pharmacy according to the provider's policy.

Inspectors wroteBased on observation, interview and policy review the provider failed to: *Ensure resident medications were secured for one of two medication carts four out of five times during the observed medication pass in the dining room. *Ensure expired influenza vaccines in one of one medication refridgerator were removed and disposed of and and were not available for resident use. 1. Observation and interview on 8/9/23 8:25 a.m. of registered nurse (RN) D during the medication pass in the resident dining room revealed: *Her medication cart was located in the doorway into the dining room. *She had walked away from the medication cart and into the dining room to give medications to three residents without locking the medication cart. *There were residents and staff walking past the medication cart that was unlocked while the RN was away from the medication cart. [...]

Inspectors wroteBased on interview, observation, and record review the provider failed to ensure one of one sampled resident (11) received recommended routine dental services to prevent tooth extractions. Interview on 8/7/23 at 5:10 p.m. with resident 11 revealed she: *Was missing a few teeth and her teeth were discolored. *Stated that her tooth hurt and she had an appointment to have it pulled. *Had received Tylenol for the pain. Interview on 8/10/23 at 8:28 a.m. with resident 11 regarding her dental issues revealed she: *Had cream of wheat for breakfast. *Had difficulty chewing solid foods. *Had an upcoming dental appointment to have two teeth pulled on the left side. *Had no help from staff in brushing her teeth and felt she needed more assistance. *Needed to brush her teeth daily. *Had numerous toothbrushes that were kept in her bathroom cupboard, in a yellow plastic basin. Observation on 8/10/23 8: [...]