Oglala Sioux Lakota Nursing Home

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview; the facility failed to dispose of foods by their best by dates and failed to store the scoops for the flour, breadcrumbs, and sugar in a manner to prevent the potential for cross contamination. This had the potential to affect all residents who ate foods prepared in the kitchen. The facility census was 36. A.A record review of the 2022 Food Code from the United States Food and Drug Administration revealed in Annex 3 that it is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. An observation on 12/15/2025 at 9:56 AM in the dry storage area of the kitchen revealed: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to submit their investigation within 5 working days for 1 (Resident 41) of 3 sampled residents' fall with injury. The facility census was 36. A record review of the facility's undated Abuse Prevention Policy revealed a written report will be provided to the State within five working days of the Administrator receiving the report. A record review of an undated, facility provided document titled List of Reportables revealed there had been a fall with injury on 10/26/2025. A record review of Resident 41's Progress Note dated 10/26/2025 revealed the resident had a fall with a laceration to their forehead and a skin tear to their left elbow that day. The resident was sent to the emergency room and returned to the facility the same day with sutures to their forehead. [...]

Inspectors wroteBased on record review and interview, the facility failed to submit accurate Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) for 2 (Residents 6 and 32) of 12 sampled residents. The facility identified a census of 36 residents. A. A record review of Resident 6's care plan in Point Click Care (PCC- an electronic medical record platform) revealed Resident 6 was admitted [DATE]. Record review of Resident 6's annual MDS assessment dated [DATE], Section K, item K0200 Resident's most recent weight was given as 132 pounds. Item K0300 was marked yes for weight loss and, the resident was not on a physician-prescribed weight-loss regimen. Weight loss was further defined in MDS Item K0300 as 5% or more in the last month or 10% or more in the last six months. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.006.09(I)(i)(3) Based on record review and interviews, the facility failed to implement interventions to prevent falls for 3 (Residents 1, 2, and 3) of 3 sampled residents. The facility census was 42. Findings Are: A record review of facility policy Falls-Clinical Protocol, with a revision date of March 2018 revealed that for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observations, interviews, and record reviews; the facility failed to implement new interventions to prevent significant weight loss for 1 (Resident 20) of 4 sampled residents. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews; the facility failed to ensure foods were disposed of or consumed prior to best-by and use-by dates, and failed to ensure food practices were conducted as required to prevent the potential for foodborne illness. This had the potential to affect all 47 residents who resided within the facility and ate foods prepared in the kitchen. A. An initial kitchen tour observation on 9/9/2024 at 9:16 AM revealed the following: In the dry food storage area: -Eleven 32-ounce containers of [NAME] Ready-care no sugar added 1.7 high calorie high protein nutrition drink with best by date of 5/7/24. -Three 4-ounce cups of 'Gelatein 20' high protein gelatin with an expiration date of 7/20/24. -Fourteen 28-ounce packets of Jell-O brand dry chocolate pudding mix with an expiration date of 6/12/24. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observations, interviews, and record review; the facility failed to administer medication at the right time and to ensure the medication error rate was less than 5% for 3 (Residents 11, 43, and 98) out of 5 sampled residents. The medication error rate was 35.71%. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B); 12-006.18(D) Based on observations, record reviews, and interviews, the facility failed to ensure a PAP (Positive Airway Pressure-a machine that delivers just enough air pressure to a mask worn over the nose or mouth to keep the upper airway passages open) mask was cleaned per facility policy to prevent infection for 1 (Resident 2) of 2 sampled residents for respiratory care, failed to implement enhanced barrier precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 Nebraska State Statute 71-6023 Based on record review and interview, the facility failed to ensure the required information was included in the written notice of transfer for Resident 8 upon transfer to the hospital. This affected 1 of 1 resident sampled for hospitalization. The facility census was 47.

Inspectors wroteLicensure Refence 175 NAC 12-006.09(C)(ii) Based on interview and record reviews, the facility failed to complete a significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual resident) for 1 (Resident 20) of 12 sampled residents. The facility identified a census of 47 at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to complete and transmit a Discharge Minimum Data Set (MDS-a federally mandated comprehensive assessment of each resident's functional capabilities) for Resident 8 upon hospitalization. This affected 1 of 1 resident sampled for discharge. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interviews; the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated comprehensive assessment of each resident's functional capabilities) for Resident 2 regarding a Positive Airway Pressure (PAP) device and for Resident 9 regarding anticoagulant use. This affected 2 of 12 residents reviewed for MDS accuracy. The facility census was 47.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(E) Based on interviews and record reviews, the facility failed to develop a comprehensive care plan regarding behaviors and non-pharmacological interventions for 1 (Resident 40) of 12 sampled residents. The facility identified a census of 47 at the time of the survey.

Inspectors wroteLicensure Reference 175 NAC 12- 006.09(F)(iii) Based on interviews and record review, the facility failed to revise the activities of daily living (ADLs) care plan to reflect current status for 1 (Resident 20) of 12 sampled residents. The facility identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to implement interventions to prevent constipation for Resident 22. This affected 1 of 1 resident sampled for bowel care. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on record reviews and interviews, the facility failed to develop and implement interventions to prevent elopement for 1 (Resident 23) of 1 sampled resident. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on record reviews and interviews, the facility failed to ensure Resident 2 had a Positive Airway Pressure (PAP) device order that included settings. This affected 1 of 2 residents sampled for respiratory care. The facility census was 47.

Inspectors wroteBased on interviews and record reviews, the facility failed to attempt a gradual dose reduction as required for psychotropic medications (medications that treat mental illness) for 1 (Resident 16) of 5 sampled residents. The facility identified a census of 47.

Inspectors wroteLICENSURE REFERENCE NUMBER 12-006.18C1 Based on observations, interviews and record review; the facility failed to 1) prevent potential cross contamination between clean and dirty laundry and 2) failed to ensure airflow was venting outside of the facility. This had the potential to affect all facility residents who received laundering services. The facility identified a census of 38 residents at the time of the survey.

Inspectors wroteLicense Reference Number 175 NAC 12-006.06B Based on record review and interviews, the facility failed to address and resolve grievances for five residents (Residents 2, 12, 16, 17, and 26). The facility identified a census of 38 residents at the time of the survey.