St. Camillus Health Center

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R1 and R2) of 2 residents with allegations of abuse and injuries of unknown origin were reported to the state agency and one or more law enforcement entities.* On 6/13/25, R1's daughter Companion-K allegedly overheard Certified Nursing Assistant (CNA)-I verbally abusing R1 when providing cares to R1. The facility did not report this allegation of abuse to law enforcement.* On 6/13/25, the facility was informed by R2's wife of bruising and swelling of unknown origin with R2's right foot. R2 had an X-RAY of R2's foot on 6/14/25, which showed a fracture of the 5th metatarsal in R2's right foot. The Registered Nurse (RN) Supervisor did not notify the Nursing Home Administrator (NHA)-A of the injury with fracture until 6/16/25. [...]

Inspectors wrote2.) R24 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease with late onset, delirium due to known physiological condition (progressive disease that destroys memory and other important mental functions), repeated falls, and other disorders of bone development and growth, right tibia, and right fibula. R24 currently has an activated health care power of attorney (HCPOA). R24's Quarterly Minimum Data Set (MDS) completed 3/3/25 documents short and long term memory impairment and R24 is severely impaired for daily decision making. R24 has range of motion impairment (ROM) on 1 side of lower extremity. R24 requires substantial/maximum assistance for mobility and partial/moderate assistance for transfers. No trial of bladder and bowel toileting program is documented on R24's MDS. R24 is frequently incontinent of bladder and bowel. [...]

Inspectors wrote2.) The facility's Enhanced Barrier Precautions policy effective 7/15/22 documents: . Purpose of Enhanced Barrier Precautions(EBP) EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high-contact Resident care activities for Residents known to be colonized or infected with a MDRO as well as those at increased risk of catching a MDRO (e.g. Residents with wounds or indwelling medical devices) Enhanced Barrier Precautions require: -The use of gown and gloves only for high-contact Resident care activities (unless otherwise indicated as part of Standard Precautions). [...]

Inspectors wroteBased on observation and interview, the Facility does not conduct regular inspection of all bed rails as part of a regular maintenance program to identify areas of possible entrapment for 4 (R1, R24, R28 and R392), of 4 Residents observed with bilateral enabler bars on the beds during the survey process. Findings Include: The facility's Proper Use of Bed Rails effective 7/18/24 documents: .Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Installation and Maintenance of Bed Rails 12. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: iii. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations involving potential abuse (R1) were thoroughly investigated for 1 of 4 reviewed facility reported incidents. *On 6/13/24, 2/21/25, and 3/5/25, the facility submitted facility reported incidents (FRI) involving R1 and allegations of R1 and sexual misconduct. All three FRIs were not thoroughly investigated by the facility. Findings Include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property updated 4/29/21 documents: .E. Investigation It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Procedure: The investigation is the process used to try and determine what happened. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not assess the risk for possible entrapment and review the risks & benefits and obtain consent on a quarterly basis for 2 (R1 and R24) of 4 Residents observed having side/bed rails. Findings Include: The facility's Proper Use of Bed Rails effective 7/18/24 documents: .Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Policy Explanation and Compliance Guidelines: Resident Assessment 1. [...]

Inspectors wrote1 of 3 Resident #9 Abuse Interview with NHA and DON 01/24/24 11:19 AM Came to the facility from AL for increased in care. were receiving 1:1 caregiver. Doing well sharing the room. Different interventions, at first slept in the same bed, family never wanted them in the same room always. Situation were they were seeking out for each other, and it was a safety situation because they were pulling on each other. Them seeking out companionship became then stopped and stated, in order for them to get a restful night, needed to separate them out so they can still see each other. Aggressive or negative contact between the two of them? - 1/24/23 bed was in the same room together beds together, grabbing and pulling at clothing. Discoloration to Mrs. [NAME]. Investigation completed. 5/28/23 1800 - CNA reported [NAME] punched Mrs. [NAME]. beds were separated at that time. [...]

Inspectors wrotePot for all FACILITY Kitchen Initial Kitchen Tour: 01/22/24 9:49 AM Interview with DM (Assistance Dietary Manager) completed: 01/22/24 9:49 AM Assist DM Name: [NAME] Credentials: Service Aid Manager and in school with Univ. South Dakota for Food Director Certification. 4 dietary manager in the building and all work somewhat with the SNF. 1/23/24 10:00 AM interview with DM [NAME] - has associate degree in food service. RD present daily, full time on site. Experience: 10 years Food Code Used: State food code Clinical Dietitian Name: [NAME] Time In Facility: Full time on site. Who completes resident assessments: RD Who meets with new residents regarding preferences: RD Vender: Sysco, Rynhardt Delivery Days: Tuesday and Friday. When do they begin temperature checking and serving? Cooking temps are done in the main kitchen. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect 43 of 43 residents residing in the facility. Staff did not cool foods with an approved cooling method. Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did not ensure a can opener was clean.

Inspectors wroteBased on staff interview and record review, the facility did not ensure all allegations of abuse and injuries of unknown origin were reported to the State Agency (SA) for 2 Residents (R) (R4 and R9) of 2 sampled residents. On 5/28/23 at approximately 6:00 PM, staff witnessed R4 punch R9 on the right side of the face. The facility did not report the allegation of abuse to the SA. On 1/28/23 at approximately 11:00 PM, Registered Nurse (RN)-C entered the shared room of R4 and R9 and observed R9 laying on a floor mat next to R4's bed. R4 was pulling at R9's arms. Despite redirection, R4 continued to pull and grab at R9's right arm which contained a bleeding skin tear. The facility did not report the allegation of abuse to the SA. On 1/24/23 at approximately 4:15 AM, RN-C entered the shared room of R4 and R9 and observed R4 grabbing and undressing R9. [...]

Inspectors wrote2 of 2 Resident #9 Abuse Interview with NHA and DON 01/24/24 11:19 AM Came to the facility from AL for increased in care. were receiving 1:1 caregiver. Doing well sharing the room. Different interventions, at first slept in the same bed, family never wanted them in the same room always. Situation were they were seeking out for each other, and it was a safety situation because they were pulling on each other. Them seeking out companionship became then stopped and stated, in order for them to get a restful night, needed to separate them out so they can still see each other. Aggressive or negative contact between the two of them? - 1/24/23 bed was in the same room together beds together, grabbing and pulling at clothing. Discoloration to Mrs. [NAME]. Investigation completed. 5/28/23 1800 - CNA reported [NAME] punched Mrs. [NAME]. beds were separated at that time. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 Resident (R) (R139) of 14 sampled residents. On 1/22/23, Surveyor observed medications left at R139's bedside. R139 did not have a self-administration of medication assessment or a physician's order to self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not monitor for adverse reactions of a high risk medication for 1 Resident (R) (R16) of 5 residents reviewed for unnecessary medications. R16 had an order for morphine sulfate (concentrate) solution (an opioid medication) 20 mg/ml (milligrams per milliliter) as needed (PRN) for pain at a level 4-6 or shortness of breath (SOB). The facility did not monitor for adverse side effects or the effectiveness of the medication.

Inspectors wroteBased on staff interview and record review, the facility did not monitor for adverse reactions or the effectiveness of psychotropic medication for 2 Residents (R) (R187 and R16 ) of 5 residents reviewed for unnecessary medications. R187 had an order for .5 mg (milligrams) of as needed (PRN) lorazepam (Ativan) (a psychotropic medication used to treat anxiety). The facility did not monitor for adverse reactions or the effectiveness of the medication and R187's order did not contain an end or duration date. In addition, R187 had an order for sertraline 25 mg daily for depression. The facility did not monitor for adverse reactions or the effectiveness of the medication. R16 had an order for lorazepam 0.5 mg PRN for restlessness/anxiety. The facility did not monitor for adverse reactions or the effectiveness of the medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 6 errors occurred during 26 opportunities which resulted in a 23% medication error rate that affected 2 Residents (R) (R18 and R16) of 3 residents observed during the medication pass. On 1/23/24 at 8:22 AM, Surveyor observed Licensed Practical Nurse (LPN)-F crush and administer R18's medication. R18 did not have an order to crush medication. On 1/23/24 at 9:10 AM, Surveyor observed staff administer the wrong medication to R16.

Inspectors wroteBased on observation and record review, the facility did not ensure its medication error rate was not 5 percent or greater. The facility medication error rate was 10.53%. * R17 did not receive Vitamin D or Calcium Carbonate as ordered. * R238 did not receive Diclofenac gel as ordered and received Lidocaine patch which was discontinued.

Inspectors wroteBased on observation and record review the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (R8 and R17) residents residing in the facility. Facility staff touched medications with their bare (ungloved) hand during medication pass observation.