Jenkin's Living Center

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure that resident medications were secured by three of three licensed nurses, contracted travel licensed practical nurse (LPN) I, LPN M, and registered nurse (RN) nurse manager H, who left medication carts unlocked and unattended.

Inspectors wroteA. Based on observation, interview, and policy review, the provider failed to ensure infection control practices were followed by three of three observed certified nursing assistants (CNA) (D and E) and one of one registered nurse (RN) G when assisting three of four sampled residents (2, 6, and 44) with personal care.

Inspectors wroteBased on the interview, call light log documentation review, and policy review, the provider failed to ensure the staff responded promptly to one of two sampled residents (2) who reported being incontinent (involuntary urine or bowel leakage) while waiting for her call light to be answered. Findings Include: 1. Interview on 5/19/26 at 10:39 am with resident 2 revealed she had concerns that when the facility was short on staff, her call light was not answered quickly enough. She stated, we wait forever to get the call light answered. This caused her to be incontinent of bowel. She stated, she feels embarrassed and frustrated when this happens.2. Resident 2 admitted into the facility on 2/1/2021. Review of resident 2's electronic medical record (EMR) revealed her 4/7/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact. [...]

Inspectors wroteBased on observation, interview, manufacture instruction review, and policy review, the provider failed to ensure that two of three dish machines reached the minimum temperatures for the wash and rinse cycles before washing the dishes.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to ensure a contracted licensed practical nurse (LPN) (F) had followed nursing professional standards of practice for the preparation of one of one sampled resident's (1) physician-ordered medication administration delivered through a syringe driver according to the provider's policy. That failure resulted in a medication error.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for: *The maintenance and disposal of resident care items in one of one shower room. *Transmission based precautions by four of four staff (certified nursing assistant (CNA) T, CNA X, licensed practical nurse (LPN) P, and wound care nurse (WCN) I) for five of five sampled residents (62, 68, 25, 6, and 66) who had care concerns requiring personal protective equipment (PPE). *Hand hygiene and glove use by five of five staff (CNA W, LPN P, LPN DD, LPN N, and staff development coordinator (SDC) H) for four of four observed sampled residents (6, 66, 59, and 328).

Inspectors wroteBased on observation and interview, the provider failed to maintain resident rooms and resident common areas in a clean manner free from strong odors, sticky floors, and damage to the walls and bathroom tiles for at least seven resident rooms, at least one resident common area, and at least one shower and one tub room.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for: A. One of one sampled resident (19) who received hospice services. B. Five of five residents (6, 7,15, 19, and 41) who received a pureed diet and were included in the paid feeding assistants program. C. Five of five sampled residents (6, 25, 62, 66, and 68) who required transmission-based precautions (TBP). D. Three of three sampled residents (40, 45, and 70) who required monitoring for medications they received. E. One of one sampled resident (10) who required placement on a secure memory unit.

Inspectors wroteBased on observation, interview, and record review, the provider failed to properly store products determined to be unsafe for cognitively impaired residents for at least 10 residents (7, 9, 15, 23, 36, 38, 40, 44, 46, and 69) on one of two memory care units. Findings Include: 1. Observations on 1/28/25 at 10:25 a.m. in resident 36's room revealed: *There was a sign posted on the mirror in the bathroom that read, Any product with 'Keep Out of Reach of Children' printed on its label needs to be kept on a closet shelf, i.e alcohol, mouthwash, [NAME] 24 [a moisturizing body cream], Baza Cleanse [a no-rinse lotion], deodorant, etc. Thanks! -Mouth Rinse, deodorant, and toothpaste were stored on a shelf in the bathroom and were accessible to the resident. *CPAP (continuous positive airway pressure) cleaning wipes were stored on top of the resident's dresser and accessible to the resident. [...]

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure five of five residents (6, 7,15, 19, and 41) who received a pureed diet and assessed to have complicated eating problems were not assisted to eat by paid feeding assistants.

Inspectors wroteBased on observation and interview, the provider failed to ensure call light systems were accessible to residents in two of two observed resident shower/tub rooms, and five of eleven observed resident bathrooms (rooms 273, 278, 280, 286, and 288).

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure the posted daily staff data: *Was displayed in a prominent area accessible to all residents and visitors. *Included the resident census. *Included the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift and the resident census.

Inspectors wroteBased on observation, interview, record review, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure an integrated plan of care had been developed and made accessible between the provider's nursing staff and hospice agency for one of one sampled resident (19) who received hospice services.

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 an unwitnessed fall and required hospitalization for injuries the next day. This 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 policy review, the provider failed to ensure interventions of regular toileting, checking and changing incontinent briefs, or repositioning were consistently implemented for six of six sampled residents (15, 14, 13, 5, 12, and 2) who developed pressure ulcers after their admission to the facility.

Inspectors wroteBased on interview, record review, observation, and policy review, the provider failed to ensure one of one sampled resident (1) was free from an injury caused by the use of a mechanical lift sling.

Inspectors wroteBased on observation, interview, electronic medical record review (EMR), and policy review, the provider failed to ensure staff interactions and services were provided in a manner that maintained a sense of dignity and respect for the following: *One of one sampled resident (3) by maintaining privacy during personal care. *Two of two sampled resident (2 and 1) resident in honoring their preference for wake time. *Two of two sampled residents (2 and 13) by using their proper name. *One of nine sampled residents (3) who needed a call light to call for assistance.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure oral care was consistently performed and accurately documented for nine of nine sampled residents (16, 17, 18, 19, 20, 2, 3, 4, and 5).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure an allegation of neglect made by one of one sampled resident (1), was reported to the South Dakota Department of Health (SDDOH) within twenty-four hours from the time that the provider was made aware of the allegation.

Inspectors wroteBased on interview, record review, South Dakota Department of Health (SD DOH) incident report review, and manufacturer's recommendations review, the provider failed to ensure one of one sampled resident (13) was assessed for the appropriate lift type Maxi Move ( a mechanical device used to transfer residents), the correct size of sling, and the number of staff required to perform a transfer with a Maxi Move lift safely.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure proper sanitary conditions were followed for 72 of 72 residents who received meals from three of three kitchens; that failure had the potential to affect all 72 residents for foodborne illnesses. Specifically, the provider failed to monitor the temperatures for three of three mechanical dishwashers with incomplete temperature sanitizing logs.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow, revise, and update care plans for five of twelve sampled residents (28, 29, 41, 50, and 67) to reflect their current care needs.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure orientation had been completed for six of six sampled temporary staff, including four certified nursing assistants (CNAs) (O, P, Q, and R) and two licensed practical nurses (LPNs) (S and T) prior to working directly with residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (18) had received notification of a bed hold notice upon transferring out of the facility.

Inspectors wroteBased on record review, observation, and interview the provider failed to ensure two of two sampled residents (7 and 50) were assessed accurately for weight (wt) loss and accurate Minimum Data Set (MDS) coding.

Inspectors wroteBased on observation, interview and record review the provider failed to ensure two of two sampled residents (7 and 50) had physician involvement associated with weight loss.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure two of two mechanical lifts and body slings were properly disinfected between resident use on two of two observed occasions.