Highmore Health

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one resident (1) identified at risk for elopement (leaving the facility without staff knowledge) who left the building from the east door on 1/17/26 and was found by a citizen. The east door was not alarmed or monitored at the time of the resident's elopement. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *The cleaning and storage of nebulizer machines and equipment (a device that converts liquid medication into an inhalable mist) for three of three sampled residents (6, 10, 18) who used a nebulizer machine. *The cleaning and storage of a BiPAP machine (device that pushes pressurized air into your lungs) and equipment for one of one sampled resident (10) who used a BiPAP machine. *The maintenance of one of one whirlpool bath chairs in a safe and cleanable condition. *The cleaning, storage, and use of shared personal care items found in one of one whirlpool room. *The storage of items in two of two designated clean linen closets. [...]

Inspectors wroteBased on observation, interview, and policy review the provider failed to follow standard food safety practices for: *One of one cook (G) who had not changed her gloves or washed her hands while serving resident food items to prevent potential contamination. *Kitchen equipment that had not been cleaned to maintain a sanitary environment.

Inspectors wroteBased on interview, observation, and grievance review, the provider failed to ensure a private area was available for residents and families to meet. This concern was identified by four residents (6, 13, 17, and 22).

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure an investigation had been conducted and documented to rule out abuse and neglect for one of one sampled resident (26) who had sustained a skin laceration while being transferred to the bath chair by staff with the use of a total mechanical lift.

Inspectors wroteBased on the Payroll Based Journal (PBJ) record review and interview, the provider failed to submit PBJ data accurately for three of four federal fiscal quarters (Quarter 1, 2023; Quarter 3, 2023; and Quarter 4, 2023).

Inspectors wroteBased on interview, resident council meeting minutes review, and policy review, the provider failed to ensure: *Resident council meetings were conducted on a monthly basis. *Residents were notified of the time and place of the resident council meetings. *There was an investigation, follow-up, and documented responses to resident council grievances brought forward by an undisclosed number of residents identified in three of five monthly meeting minutes sampled (September 2023, December 2023, and January 2024).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were updated to accurately reflect the current care needs of four of five sampled residents (2, 11, 31, and 189) including fall interventions, code status, and assist bars.

Inspectors wroteBased on observation, record review, and interview, the provider failed to ensure a safe environment, free from potential accident hazards in the room of one of one sampled resident (32) with a history of multiple falls. Findings Include: 1. Observation on 2/26/24 at 11:22 a.m. of resident 32 while in his room revealed: *He had been asleep, seated in his wheelchair, with his feet on the floor, next to his bed, facing his recliner. *There were four areas of flooring around and his recliner that had peeled up and had visible underflooring. -Those areas ranged in size from approximately three inches by four inches to approximately five inches by six inches. *He moved his feet and revealed another area of exposed underflooring and flooring with peeled edges. *He then moved his wheelchair back and the wheel caught on one of the exposed edges. 2. Observation on 2/27/24 at 11:19 a.m. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure controlled medications (drugs easily diverted by staff) were securely stored for one of one observed medication rooms.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure food items were appropriately stored in a safe and sanitary manner in one of one observed kitchen for the following: *One of one commercial refrigerator that contained food items that were not labeled, dated, or discarded by the use by date, and staff items were stored where resident food items were stored. *One of one upright freezer contained food items that were not labeled or dated. *One of two small chest freezers that did not have a functioning thermometer to ensure foods were stored at a safe temperature. *One of one commercial freezer contained food items that were not stored, labeled or dated. *Two of two containers of a food thickening product had scoops stored in them. *One of one container of powdered milk had a scoop stored in it. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure one of one whirlpool (WP) tub was cared for in a manner that maintained the quality of the WP tub's interior surface.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure a safe environment, free from potential accident hazards for all residents who may be at risk for falls or other injury.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a baseline care plan accurately reflected the resident's care needs for one of one sampled newly admitted resident (90).

Inspectors wroteBased on closed medical record review and interview the provider failed to ensure one of one sampled resident's (37) closed record included a recapitulation (a summary of the resident's nursing home stay).

Inspectors wroteBased on observation, interview, medical record review, and policy review, the provider failed to ensure one of five sampled residents (11) received benefits of use versus the risks of use for bilateral bed assist bars on his bed, had an informed consent signed, and had alternatives attempted before installation and use of those bilateral bed assist bars on his bed.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to investigate two incidents of resident-to-resident altercation involving two of two sampled residents (89 and 90).

Inspectors wroteBased on observation, interview, record review and policy review, the provider failed to ensure one of one sampled resident (90) was protected from verbal and physical abuse by his roommate (resident 89).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to investigate and report alleged abuse to the South Dakota Department of Health (SD DOH) for two of two sampled residents (89 and 90) who had inappropriate verbal and physical behavior between each other and one of the residents (90) was cognitively impaired.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to assess and document timely, implement, monitor, and review and update care for three of four sampled residents (21, 28, and 89) who had multiple medical conditions and were at risk for pressure ulcer development.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure five of five newly admitted residents (9, 28, 32, 89, and 90) had a baseline care plan established and reviewed with the resident, their representative, or their responsible family member.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure: *One of one sampled resident (28) and her family had the opportunity to participate in the plan of care process. *Care plans were reviewed and revised to ensure care needs were accurately reflected for 4 of 14 sampled residents (18, 21, 89, and 90).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure interventions were in place and updated for one of one sampled resident (90) who had multiple falls from 2/11/23 through 2/20/23.

Inspectors wroteInterview on 3/2/23 at 12:44 p.m. with administrator A revealed she was unsure if other alternatives to side rails were tried prior to implementing side rails on the resident's beds. 5. Observation and interview on 2/27/23 at 11:38 a.m. with resident 28 revealed: *Assist bars on both sides of her bed and she used them to turn and reposition herself. *Resident 28 stated she did not recall having a discussion regarding the assist bars including the risks and benefits of having the assist bars on her bed. Review of resident 28's medical record revealed: *She had been admitted on [DATE]. *She had good memory recall and could make her needs known. *She had required one staff person's support to ensure all her needs had been met. -Those needs had included transfers, dressing/undressing, personal hygiene, walking/moving, toileting, and repositioning in her bed. [...]