Palisade Healthcare Center

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, document review, observation, interview, and policy review, the provider failed to protect the resident's right to be free from neglect for three of three sampled residents (1, 2, and 3) whose incontinence (involuntary urine or bowel leakage) products were not changed timely and the residents were not repositioned per leadership expectations by three of three CNAs (C, E, and P), for one of one sampled resident (4) who reported an unidentified staff member did not change resident 4 for a long period of time and he developed skin irritation and open sores to his perineal area, from abuse for one of one sampled resident (3) whose perineal area (genital area) was cleaned roughly by one of one certified nursing assistant (CNA) (Q) and developed an open sore, from neglect for two of two [...]

Inspectors wroteBased on observation and interview the provider failed to ensure call lights (a communication tool that enabled residents to alert staff for assistance) were within reach for 10 of 10 sampled residents (3, 5, 6, 8, 9, 10, 11, 12, 13, and 14) that would allow the residents to request assistance from staff promptly.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure 1 of 1 resident (7) supra pubic catheter (a tube placed in the bladder to remove urine from the body) was irrigated (flushed) using a sterile graduated cylinder for the saline and vinegar solution that was used to flush her supra pubic catheter by licensed practical nurse (LPN) I.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake report review, record review, interview, and policy review, the provider failed to ensure staff provided quality care related to skin injury prevention and skin management processes including completing skin evaluations, accurate communication, accurate documentation, and implementing interventions and treatment orders for one of one sampled resident (1) who developed skin injuries to his left lower leg, left foot, and right lower leg and was hospitalized related to those wounds. Those failures put all residents at potential risk for serious injury or harm. Immediate Jeopardy (IJ) at F684 began on 11/18/25 when the provider failed to evaluate resident 1's left lower leg, left foot, and right lower leg wounds and implement appropriate follow-up procedures. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and manufacturer's operator's instructions review, the provider failed to ensure:*The safety of one of one sampled resident (1) who fell from a total body lift (a mechanical lift and sling used to lift a person's full body) and sustained a hematoma (an injury that causes a localized collection of blood under the skin) while being transferred by one of one licensed practical nurse (LPN) (C) and one of one certified medication aide/certified nursing assistant (CMA/CNA) (F).*The sling sizes for eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, and 8) who used a total body lift for transfers were assigned according to the sling's manufacturer's instructions. Findings Include:1. [...]

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to adequately identify and effectively implement pressure ulcer (skin and/or underlying tissue injury due to prolong pressure) preventative interventions for residents identified at risk for developing pressure ulcers for:*One of one sampled resident (3) who developed a pressure ulcer to her heel.*One of one sampled resident (27) who developed a pressure ulcer to her coccyx (tailbone).

Inspectors wroteBased on observation, interview, and record review the provider failed to ensure staff responded timely to residents' call lights for 7 of 18 residents (3, 6, 8, 14, 19, 28, and 54) who expressed complaints regarding staff not responding timely to their call lights to address the residents' needs.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *Three of three medication carts were free from medications beyond the use by date after opening for six of six residents sampled. *Two of three shower rooms were free from medications that were intended for individual resident use and without access to staff that were not qualified to administer medications. *Drugs and biologicals are stored according to the facilities policy in two of three shower rooms and one of three medication carts. *Drugs and biologicals are free from access and administration by staff other than trained nurses and certified medication aides (CMAs).

Inspectors wroteBased on interview, observation, record review, and policy review, the facility failed to ensure:*The food was appetizing and served at a satisfactory temperature.*Accurate menus were provided to residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow infection prevention and control processes to ensure:*Proper hand hygiene, glove use, and gown use, was performed by eight of eight observed staff members (certified nursing assistant (CNA) R, K, L, and O, licensed practical nurse (LPN) I, housekeeper Z, and registered nurse (RN) H) during resident care for four of four sampled residents (1, 3, 5 and 27). *Contact precaution protocols were followed by one of one observed LPN (C) during resident care activities and medication administration for one of one sampled resident (52) related to an infectious bacterial infection in her stool.*The mechanical lift was cleaned between resident use by four of four observed staff members (CNAs L, O, and P, and LPN N) during two of three missed opportunities. 1. Observation on 8/5/25 at 10:24 a.m. [...]

Inspectors wroteBased on record review and interview, the provider failed to ensure the Medicare notice given to the resident and/or the representative was:*Provided on the current form and completed according to the form's instructions for one of two sampled resident (1) who had discharged from Medicare skilled part A services and remained in the facility.*Completed according to the form's instructions for one of two sampled resident (22) who had discharged from Medicare part A services and remained in the facility.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and policy review, the provider failed to report an allegation of suspected neglect for one of one sampled resident (56). This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review the provider failed to ensure one of one sampled resident's (1) care plan had been updated to reflect his current needs regarding the fall intervention for his use of a wheelchair with an anti-rollback bracket (to prevent it from rolling backward) as indicated in the provider's SD DOH FRI following the residents fall on 1/17/25 when he sustained a head laceration that required evaluation and stitches at a hospital.

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 one of one resident (1) had an antiroll back bracket on his wheelchair to prevent it from rolling backwards when he attempted to stand up and self-transfer after he fell on 1/17/25 sustaining a laceration to his head and going to the hospital for sutures to that area.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to protect one of one (1) resident from neglect due to failure to provide physician-ordered care.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review and interview the provider failed to ensure the care plan reflected the current individualized care needs for one of one sampled resident (1) with physician-ordered skin treatments.

Inspectors wroteBased on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure one of one certified medication aide (CMA) (C) administered a medication (med) according to pharmacy directions for one of one sampled resident (1) who required the use of the med to stabilize phosphorus levels in his blood.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to provide a homelike environment that was free from excessive foul odors and large amounts of dust, dirt, debris, rust, and other cosmetic issues for all 49 residents living at the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *One of one refrigerator in the kitchen storage room used for storing resident foods: -Was maintained for cleanliness. -The food stored in the refrigerator was monitored for outdated food items consistently. *Groceries delivered in cardboard boxes were not left on the floor of the pantry and the walk-in freezer. *Food items set up on kitchen carts for the next meal were covered until they were brought to the dinner table. *The following kitchen equipment and the surrounding environment was maintained in a clean and sanitary manner: -Two of two ovens, one convection, and one oven/range. -One-of-one stove hood filter panels. -One of one steam table. -One of one vegetable sink. -One stainless steel counter on the back wall holding a large mixer on the counter. [...]

Inspectors wroteBased on observation, interview, record review, policy review, and manufacturer's guideline review, the provider failed to ensure: *Four of four sampled resident's (6, 11, 34, and 38) oxygen concentrator machines were free from dust buildup. *One of one shared resident oxygen concentrator machine was free from dust and debris buildup. *One of one sampled resident's (34) oxygen tubing was managed in a way that minimized the risk of contamination. *Physician's orders were followed for continuous oxygen administration for one of one sampled resident (1).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the following: *Resident use items, such as mechanical lifts, therapeutic exercise machines, door handles, and handrails were maintained in a clean and sanitary manner. *Supply closets were maintained in a manner that prevented the accumulation of dust and trash, and ensured the supply of resident-use items were discarded after the expiration date. *Infection control guidelines were maintained during the following: -Three of twenty-six medication administration observations by licensed practical nurse (LPN) M and LPN L. -Wound care performed by two of two LPNs (R and S) for two of two sampled residents (1 and 24) on enhanced barrier precautions (the practice of using gowns and gloves when performing certain high-contact cares for certain residents).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure dignity was maintained for one of one sampled resident (26) who was parked in the middle of a hallway after requesting help to use the restroom by one of one social services designee (SSD) (C) and was told to wait for another staff member. The resident waited 20 minutes and in that time frame was incontinent.

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure one of one sampled resident's (1) advance directive wishes were consistent between the resident's records, facility's code status binder, and the nursing staff's cheat sheet records.

Inspectors wrote2. Interview on 3/11/24 at 4:18 p.m. with resident 40 revealed she: *Had gotten nose bleeds. *Was concerned she was receiving too much blood thinner. *Reported she had 3 major ones [nosebleeds] while at the facility. *Stated she takes a blood thinner and baby aspirin. *Recalled having had a nosebleed last Thursday [3/7/24] that lasted from 9:00 p.m. until 3:00 a.m. *Stated, They gave me ice to get it [the nosebleed] to stop, but never came back. Interview on 3/13/24 at 2:15 p.m. with resident 40 revealed she: *Recalled LPN M: -Assisted her when she had the last nosebleed. -Had filled a glove with ice and wrapped it in paper towels. -Had placed the glove on her nose with her head down. *Stated the nosebleed lasted from 9:30 p.m. until 3:00 a.m. *Had known she was on Eliquis and 81mg of aspirin. [...]

Inspectors wroteBased on observation, interview, record review, user manual review, and policy review, the provider failed to ensure for one of one sampled resident (1) with bedrails: *They were routinely inspected checking to make sure the mattress fit the bed frame properly limiting entrapment zones. *Documentation of those inspections that included the entrapment zones.

Inspectors wroteBased on interview, closed record review, and policy review the provider failed to ensure one of one sampled resident (1) had the following: *A re-weigh of the resident was completed upon discovery of a weight variance. *Documentation to support the actions that were taken after the identification of the resident's weight loss. *Notification to the resident's representative and the physician with the a variance in his weight.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the following: *Three of sixteen sampled residents (9, 26, and 32) care plans had been updated to include the most current medical status of the residents. *Seven of sixteen sampled residents (9, 10, 14, 16, 19, 21, and 28) care plans included their current code status.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to involve resident physicians in the advanced directive process and obtain physician orders for seven of sixteen sampled residents (9, 10, 14, 16, 19, 21, and 28) who had a signed do not resuscitate (DNR) form.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure two of two nurses (F and G) administered eye drops according to the provider's policy for two of two residents (12 and 45).