Monument Health Sturgis Care Center

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding:*Hand hygiene (handwashing) and glove use by one of one registered nurse (RN) (E) during resident blood sugar level testing (measuring the amount of sugar in the blood using a glucometer or a blood glucose meter) for one of one sampled resident (29), and by one of two certified medication aides (CMA) (F) during medication administration for one of three sampled residents (24).*Hand hygiene and no gown use by one of one RN (E) during wound care for one of one sampled resident (13).

Inspectors wroteBased on observation, record review, and interview, and policy review, the provider failed to follow professional standards regarding one of one registered nurse (RN) (E) who provided a Trelegy Ellipta (a medication to improve lung function) inhaler (a portable device for administering a medication that is breathed into the lungs) to one of one sampled resident (43) who did not have a physician's order or a medication self administration assessment completed for the inhaler and was observed self administering the medication.

Inspectors wroteBased on observation, record review, interview, competency checklist review, the provider failed to follow professional standards regarding one of one certified medication aide (CMA) (F) who administered the wrong dose of medication to one of one sampled resident (24) according to their physician's order.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure resident insulin pens were labeled and discarded when they expired for two of two sampled residents' (30 and 39) whose insulin pen labels were unable to be read by the staff, and one of one sampled resident (39) who received expired insulin.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure one of one cognitively impaired sampled resident's (2) bruises of unknown origin had been thoroughly investigated to: *Identify their root cause. *Develop interventions to prevent or decrease the likelihood of them recurring. *Rule out potential abuse or neglect.

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 implement a fall prevention intervention to have a call light placed within the resident's reach to reduce the risk of falling for one of one sampled resident (1) who fell. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

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 prescribed pain medication was acquired and administered in a timely manner for one of one resident (1) who had pain. *Maintain records to account for controlled (medications with risk for abuse and addiction) medications according to the provider's policy. *Ensure proper documentation and destruction of medications according to the provider's policy.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure expired medications were removed from two of two medication carts and one of two treatment carts.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to ensure one of one allegation of controlled (medication with risk for abuse and addiction)medication diversion was reported within the required time frame.

Inspectors wroteBased on observation, interview, and policy review the provider failed to maintain appropriate temperatures for one of one high-temperature dishwasher utilized to clean dishes used to prepare and serve resident food items according to the manufacturer's instructions.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one registered nurse (RN)(J) had prepared and administered insulin according to the physician order and provider policy for one of one sampled resident (25).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure oral hygiene was provided for three sampled residents (3, 45, and 148) who were dependent on staff for their care needs according to their personalized care plan and facility policy.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure interventions to lessen the occurrence of urinary tract infections (UTI) were implemented for one of one resident (14) who had a UTI.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for: *Hand hygiene and glove use by three of four certified nurse aides (CNAs) (I, K, and L) during peri-care for three of three observed residents (11, 14, and 28). *Incontinence care provided by three of three CNAs (I, K, and L) for three of three observed residents (11, 14, and 28). *Hand hygiene assistance for one of one observed resident (14) with hand hygiene following bathroom use.

Inspectors wroteSubstantial compliance was confirmed on 4/3/24 after record review revealed the facility had followed their quality assurance process; after mechanical lift education was provided to all nursing staff; after multiple staff interviews revealed competence and understanding of the mechanical lift training; after resident interviews confirmed transfers with a mechanical lift were provided with the proper number of staff; and after observations of staff showed they performed proper transfers with a mechanical lift.

Inspectors wroteBased on closed record review, job description review, interview, and policy review, the provider failed to ensure fall management and documentation protocols had been followed after one of one closed record sampled resident (1) had fallen.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure there was licensed nursing oversight and supervision to ensure the following: *One of one CMA (I) had not crushed and administered a delayed seizure medication to one of one sampled resident (18) to prevent a medication error from having occurred. *One of one CMA (I) had received initial medication administration orientation. *One of one CMA (K) had not calculated a Lactulose medication dose for one of one sampled resident (32). *One of one CMA (J) had not decided whether or not it was safe for one of one sampled resident (47) to have taken his medications whole without crushing them. *One of one CMA (J) had received annual medication administration education or had completed a medication administration competency.

Inspectors wroteBased on observation, interview and policy review, the provider failed to ensure the following: *A homelike environment had been observed and staff assistance was provided in one of two dining rooms ([NAME]) during three of three observed mealtimes. *Conversations between residents and staff had occured in one of two dining rooms (Berry) during one of one observed mealtime. *Dignity had been maintained for two of four sampled residents (32 and 49) by covering the urine collection systems.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Proper hand hygiene and glove use during: -One of one random observations of a medication pass by one of one certified medication aide (CMA) (I) with two of two residents (9 and 19). -One of one water passes down [NAME] Hall by one of one certified nursing assistant (CNA) (T). -One of one resident's (42) personal hygiene performed by two of two CNA's (T and U). *Handling of scissors used during one of one sampled residents (49) wound care by one of one infection control (IC) nurse (E) and one of one licensed practical nurse (LPN) (F). *Ensuring one of two sampled residents (49) who had a Foley catheter had his uncovered urine collection bag kept off the floor in his room while he was in bed.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to adhere to professional standards of practice for the following: *Post-dialysis care per the provider's policy for one of one sampled resident (37). *The use of a physician ordered pain assessment scale prior to the administration of narcotic pain medication for one of one sampled resident (49).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of one closed record sampled resident (50) had a discharge summary completed after she was discharged from the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure collaborative communication was accessible to nursing home staff by one of one hospice agency for two of two sampled residents (4 and 49) who had been receiving hospice services.