Sanford Chamberlain Care Center

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, observation, and policy review, the provider failed to protect the safety of residents identified as at risk for elopement (leaving the facility without staff knowledge) when one of one sampled resident (22) crawled out a window, and two of two sampled residents (51 and 52) exited the facility without the staff's supervision.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent related to resident (36) no receiving her full dose of insulin, resident (38) not receiving her calcium/vitamin D/vitamin K due to incorrect labeling, residents (24 and 37) self-administering a medication with no assessment or orders from the physician. Those observed errors resulted in a medication error rate of 14.29%.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure that evaluations for self-administration of medication were completed for two of two residents (24 and 37) whose medications were left at the bedside by CMA N.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to maintain resident bathrooms in a clean and well-kept manner, free from damage to flooring, for one of one sampled resident (28).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (2 and 22) had a Preadmission Screening and Resident Review (PASRR) II completed. Findings Include: 1. Review of resident 22's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, post-traumatic stress disorder (PTSD) and depression. Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 14 which indicated she was cognitively intact. She had a Department of Social Services (DSS) letter dated [DATE] which indicated she had been approved for 365 days for admission or continued stay to a nursing facility effective as of the date of this letter. At that time, you may be appropriate for discharge to a lower level of care. As a result of the review, the following recommendations are made: [...]

Inspectors wroteBased on observation, record review, interview, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for two of six sampled residents (2, and 30).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure that two of two sampled residents (21 and 37) on oxygen had their tubing changed weekly.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to notify the physician of one of two sampled residents (2) who had unplanned significant weight loss (a loss of 5% (percent) of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure residents were free from significant medication errors for one of one sampled resident (36), who was not administered his physician-ordered dose of insulin by registered nurse (RN) J, which increased his risk for having diabetic complications, including hyperglycemia (an abnormally high blood sugar level). Additionally, resident 38 did not receive his calcium/vitamin D3/vitamin K medication from certified medication assistant (CMA) H because the label on the medication did not match the medication. Findings Include:1. Observation on 7/15/26 at 12:03 p.m. of registered nurse (RN) J administering Novolog FlexPen (insulin aspart, a rapid-acting insulin in a prefilled pen. A needle attaches to the pen for medication administration) to resident 36. The ordered dose was 5 units (u). [...]

Inspectors wroteBased on observation, interview, document review, and policy review, the provider failed to ensure appropriate hand hygiene was performed by one of one observed cook (Q) to meet professional food cleanliness standards.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure that 1 of 1 sampled resident 17 had his call light in reach on 7/14/26, 7/15/26, and 7/16/26 after he returned from therapeutic leave.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview, record review and policy review the provider failed to have physician orders for therapeutic leaves, to ensure no disruption in wound cares and scheduled medications supplies for care were available and sent with one of one sampled resident (33) who left the facility for therapeutic leave home visits.

Inspectors wroteBased on observation, interview, and policy review the provider failed to follow standard food safety practices, maintaining sanitary conditions in the kitchenette on [NAME]-wing, and processes to prevent foodborne illnesses for:*One of one cook (H) who had not worn gloves or performed hand hygiene (handwashing) while serving one of one sampled resident's (4) food items to prevent foodborne illnesses.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, video footage review, interview, and policy review, the provider failed to protect the resident's right to be free from physical abuse by: *One of one certified nursing assistant (CNA) (D) who responded to falling incidents with physical force and restraint for one of one sampled resident (1) with cognitive impairment. *Eight additional staff members (E, G, H, I, J, K, L, and M), identified as present at the time the physical abuse occurred, who did not intervene or report those incidents to a supervisor at the time those incidents occurred.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, record review, and interview, the provider failed to implement, review and revise interventions to reduce the risk of falls for two of two sampled residents (1 and 2) with a history of falls and to prevent subsequent falls. Findings Include: 1. Review of the provider's 6/1/25 SD DOH FRI revealed: *[Resident 2] was found on [the] floor at 1910 [7:10 p.m.] by a CNA [certified nursing assistant] .he was attempting to self transfer out of wheelchair by [his room]. *Resident 2 sustained a closed fracture of [his] left hip. *Before the fall, resident 2 was changed from [needing to use] a stand aid [a mechanical device that lifts a resident from a sitting position to a standing position] to a stand pivot with two [staff] assist [assistance]. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs for two of two sampled residents (1 and 2).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) 1/2/25 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure there was a plan of action implemented following an incident where one of one sampled resident (1) had become physically aggressive with staff and had struck another resident (2) in the face during the interaction. *Ensure one of one sampled resident (1) who had cognitive impairment was free from psychological and physical abuse by three of three certified nursing assistants (CNA) (G, K, and L) during an episode of the resident having had increased agitation and aggression. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (2) who fell, suffered head trauma, and required emergency room treatment, while attempting to sit down on a whirlpool chair when one of one sampled employee (K) failed to ensure the brakes on the whirlpool tub chair were locked.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy the provider failed to ensure one of one sampled resident (1) consumed adequate fluid intake to alleviate and prevent dehydration.

Inspectors wroteBased on the 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 sampled resident (1) had neurological checks completed after a fall.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) 9/25/24 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure the physical and psychosocial wellbeing for one of one sampled resident (1) with a history of trauma expressed feelings of fear, feeling unsafe, and suicidal thoughts that potentially increased after an unwanted entry into her room and an act of physical aggression made towards her by resident (2) who has cognitive impairment. *Ensure two of two sampled residents (2 and 3) were free from acts of verbal and physical aggression towards each other.

Inspectors wroteBased on interview, and policy review, the provider failed to ensure: *One of three sampled residents (1) had been screened for post-traumatic stress disorder (PTSD) upon admission, quarterly, annually, or upon her return from an inpatient psychiatric hospitalization for suicidal ideations. *Two of three sampled residents (2, and 3) had been screened for post-traumatic stress disorder (PTSD) upon admission, quarterly, or annually.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review and policy review the provider failed to ensure the care plans were reviewed and revised for four of four sampled residents (1, 2, 3, and 4).

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 the safety of one of one sampled resident (24) who eloped (left the facility without staff knowledge) and while he was outside of the building, fell and required evaluation at the emergency department.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure necessary food safety guidelines were followed for two of two kitchenettes located in the 100 and 200 hallways which included: *The appropriate storage and labeling of food items. *The cleaning and safe maintenance of kitchen surfaces and appliances.

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure the South Dakota Department of Health (SD DOH) had been notified of two of three incidents of elopement for one of one sampled resident (24).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (24) identified at risk for developing skin injuries and who had acquired a skin injury (wound) received: *Timely skin assessments performed by professional licensed staff. *Timely notification to his physician to obtain orders for treatment.