Good Samaritan Society Miller

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to monitor and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (5) identified at risk for developing pressure ulcers and developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his coccyx (tailbone).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed with, and a copy was provided to the resident and the resident's representative according to the provider's policy within 48 hours of the resident's admission to the facility for four of five newly admitted sampled residents (2, 5, 19, and 24).

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the staff followed professional standards of practice related to respiratory care for:*Cleaning and storing nebulizer equipment (a device used when using a nebulizer machine that converts liquid medication into an inhalable mist) for three of three sampled residents (13, 19, and 28) who used nebulizer machines.*Cleaning the Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open) for one of one sampled resident (13) who used a CPAP machine.*Cleaning and storing oxygen equipment for four of four sampled residents (13, 19, 28, and 29) who used oxygen.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to maintain a system to account for all controlled (medications with risk for abuse, addiction, and potential theft) medications for one of two observed medication carts and for one of one treatment cart in the East hall, and to document medications related to their receipt, counts, administration details, and destruction process.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of two sampled resident (4) who received an antipsychotic medications (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) and a psychotropic medication (drugs that affect brain activities associated with mental processes and behavior) had an attempted gradual dose reduction (systemic dose reduction over time to determine if the condition could be managed with a lower dose or discontinuation of the medication) (GDR) or a physician's documented rationale to support that a GDR was clinically contraindicated (not appropriate based on the resident's condition, potential risks, or adverse effects) for the use of those medications.

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure one of four sampled resident (3) who was recently admitted to hospice (specialized care for individuals with a terminal illness that focuses on comfort and quality of life rather than curative treatments) services had a significant change Minimum Data Set (MDS) assessment (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 within 14 days after the resident admitted to hospice.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed and revised to reflect the current care needs for two of seventeen sampled residents (2 and 16).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff members followed professional standards of care for:*The assessment, care, and accurate documentation regarding one of one sampled resident (4) with a newly placed suprapubic catheter (flexible tubing surgically placed in the bladder through the abdominal wall to drain urine).*Accurately entering physician's orders into the electronic medical record to ensure one of one sampled resident's (16) Haldol (medication for reducing symptoms of mental health conditions) was transcribed and administered as ordered.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the medication labels and the resident's medication administration record (MAR) matched during two of two observed medication administrations for two of eleven sampled residents (7 and 29) by certified nurse aides (CNAs)/unlicensed assistive personnel (UAPs) L and I.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure that staff were able to verify the chemical sanitation level required to sanitize the dishes used for preparation and serving residents' food. Failure of that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen and served to the residents.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (15) who was blind had his food and drink free from flies in and on it, received timely care for his incontinence needs, and received a bath as scheduled prior to attending a funeral.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, and record review the provider failed to ensure one of one resident (17) who required staff assistance with care had not developed facility acquired pressure injuries when left on a bedpan for an extended time.

Inspectors wroteBased on interview, record review, quality assurance and performance improvement (QAPI) program review, and job description review, the provider failed to ensure an effective, ongoing, and comprehensive QAPI program was in place to track and measure performance; systematically analyze underlying causes of systemic quality deficiencies; develop and implement corrective action or performance improvement activities; and monitor or evaluate the effectiveness of the corrective action/performance improvement activities, and revise the actions, as needed.

Inspectors wroteBased on interview the provider failed to ensure they had not established and maintained an infection prevention and control program.

Inspectors wroteBased on interview the provider failed to ensure that they had an infection preventionist (IP). 1. Interview on [DATE] at 3:16 p.m. with interim director of nursing (DON) B revealed: *She was told she would be the IP. *She stated she did not have her certificate for infection preventionist as it had expired. *She was not currently enrolled to regain her certification and was not going to enroll since she was an interim DON. 2. Interview on [DATE] at 4:30 p.m. with administrator A revealed she agreed they did not did not have an infection preventionist. 3. Interview on [DATE] at 5:28 p.m. with quality assurance specialist/certified medication assistant I revealed: *The former director of nursing had been the provider's infection preventionist but she had resigned from her position effective at the beginning of [DATE]. *The provider had no qualified infection preventionist.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure pest control for flies was effective.

Inspectors wroteBased on resident council meeting, observation, interview, record review, and policy review, the provider failed to ensure three of fifteen residents (1, 15, and 18) bathing preferences were followed.

Inspectors wroteBased on observation, interview, review of the provider's facility reported incident (FRI) to the South Dakota Department of Health (SD DOH), and policy review the provider failed to ensure 4 of 5 sampled residents (1, 15, 18, and 27) had their care plans were followed, updated, and revised promptly to reflect their current status and care needs.

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure one of one sampled resident's (27) physician was notified of the resident's suicidal ideation statements and safety concerns related to his staff-observed vehicle driving practices.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled residents (21) reviewed for facility-initiated transfer to the hospital.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to provide bed-hold notices to the resident and/or their representative regarding transfers to the hospital on two occasions for one of one sampled resident (21).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (27) who used an infra-red device for neuropathy pain in his feet had a current physician order for its use and had been assessed for safety of its use.