Oakview Terrace

Inspectors wroteBased on observation, record review, and interview, the provider failed to post the required daily nursing staffing information that included the facility name, total number of staff hours. and the actual hours worked by nursing staff for 33 or 33 random days reviewed in March, April, and June of 2025. 1. Observation on 6/24/25 at 9:39 a.m. of the posted nurse staffing information revealed: *It was posted on a board near the nurses' station. *It did not contain the name of the facility as required. *There were six categories of staff listed on the sheet: RN (registered nurse), LPN (licensed practical nurse), CNA (certified nursing assistant), Medication aide, Restorative aide, and shift totals. *Within each of those categories the number of staff scheduled for the day was listed by shift. *There was one RN listed for each identified shift. *The CNA area under the 6:00 a.m. to 2:00 p.m. [...]

Inspectors wroteBased on record review, interview, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for seven of seven recently admitted sampled residents (11, 14, 17, 37, 38, 40 and 195) within 48 hours of their admission to the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed for: *The storage and handling of a catheter urine drainage bag for one of one sampled resident (11) with a catheter. *The cleaning and disinfecting of shared resident lift equipment by three of three observed certified nursing assistants (CNAs) (L, M, and T)

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure a Minimum Data Set (MDS) discharge tracking record assessment was completed within the required timeframe for one of one sampled resident (12) after her death in the facility.

Inspectors wroteBased on interview, and record review, the provider failed to ensure one of one resident (7) who received an injectable diabetic medication had that medication coded accurately on the Minimum Data Set (MDS) assessment. 1. Interview on 6/24/25 at 2:45 p.m. with resident 7 revealed: *She had diabetes (a group of diseases that result in too much sugar in the blood). *She received an injectable medication weekly to treat her diabetes. *Her blood sugars were monitored by staff. 2. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated she was cognitively intact. *She had a diagnosis of diabetes. *Her blood sugars were monitored weekly by staff. [...]

Inspectors wrote7. On 6/26/25 at 11:15 a.m., a request was made to DON B for the Northview and Southview refrigerator temperature logs for April, May, and June 2025. The logs for May 2025 were unavailable for review. 8. Review of the Southview Refrigerator/Freezer Temperature Forms revealed: *REPORT ALL OUT OF RANGE TEMPS [temperatures] TO THE DIETARY MANAGER AT TIME NOTED. *The refrigerator range was listed as 35-40 F, and the freezer range was 0 OR LESS. *In April 2025: -There were 15 days with no refrigerator or freezer AM temperatures recorded. -There were no PM temperatures recorded. -The form indicated the refrigerator was out of the range six days. *In June 2025: -There were 14 days with no refrigerator or freezer AM temperature recorded. -There were no PM temperatures recorded. -On 6/3/25, the refrigerator was out of the range indicated on the form. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, record review, interview, and policy review, the provider failed to follow resident's care plans to: *Provide adequate supervision for one of one sampled resident (40) who was left unsupervised in the whirlpool tub by two certified nursing assistants (CNA) (K and Q). *Provide adequate assistance by one of one CNA (S) for one of one sampled resident (38) who fell and sustained an injury and pain that required evaluation at the emergency room. Findings Include: 1. Review of the provider's 4/29/25 SD DOH FRI revealed: *On 4/28/25 at 4:15 p.m., CNAs O and P heard [resident 40] yell Hello from the [whirlpool] tub room, and went into [the whirlpool] tub room and noted [resident 40] sitting in the whirlpool [tub] without any staff member present. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) event report review, medical record review, physical therapy evaluation review, care plan review, interview, and policy review, the provider failed to ensure one of one certified nursing assistant (CNA) (I) had followed one of one sampled resident's (7) care plan for using two staff persons to transfer resident 7 using a [NAME] Plus stand lift, resulting in a fall and a fractured hip.

Inspectors wroteBased on observation, interview, 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 residents' that required assistance during one of two observed resident meal services.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (27) was dressed in a Onesie (one-piece close-fitting garment with an opening in the back) restraint to prevent her from removing her clothing had the following: *Approval of the use of the Onesie restraint from resident 27's guardian. *An assessment to ensure the Onesie restraint was not used for staff convenience. *A physician's order for the use of the restraint. *Used the least restrictive restraint for the least amount of time. *Documented the use of the restraint in the care plan. *A routine re-evaluation to ensure the Onesie was appropriate and necessary.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Ongoing and timely skin assessments were conducted and documented by licensed nurses prior to the development of pressure ulcers for three of three sampled residents (9, 28, and 33) who had been identified as at risk for pressure ulcers. *Complete and accurate ongoing documentation of identified pressure ulcers for three of three sampled residents (9, 28, and 33) who developed pressure ulcers. Documentation to reflect: -Location and staging. -Size, depth, and presence, location and extent of any undermining g or tunneling. -Exudate, if present. -Pain, if present. -Wound bed, color and type of tissue/character, including evidence of healing. -Description of wound edges and surrounding tissues as appropriate.