St. William's Care Center

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (3) who was identified at risk for developing a pressure ulcer and developed an unstageable (wound bed not visible due to covering, such as debris, dead tissue, scabbing, or a non-removable dressing) pressure ulcer to her left heel while under their care.

Inspectors wroteBased on observations, interview, and record review, the provider failed to ensure two of two dietary staff (cook L and dietary aide P) followed the menu serving sizes for each diet offered for two of two observed meals. This had the potential to affect all residents who requested the main menu items. Findings Include:1. Observation on 2/10/26 at 11:25 a.m. in the kitchen revealed that cook L was preparing to set up the hot-serving table for the lunchtime meal service. Interview at that time with cook L revealed that most residents requested smaller portions, but she provided about four ounces of the meat option and two ounces of vegetables or two ounces of the side dish to the residents. She did not reference the dietitian approved menu at that time to verify the correct serving sizes for each prescribed resident diet.2. Observation on 2/10/26 from 11:50 a.m. to 12:19 p.m. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to:*Minimize cross-contamination via glove use during two of three meals observed by cook L and during food preparation by dietary aide T.*Properly store and sanitize food thermometers prior to use by cook L.*Maintain one of one kitchen in a clean and sanitary manner as evidenced by dusty ceiling vents throughout the kitchen, dusty ventilation fans in one of one walk-in cooler, rusty shelves in one of one walk-in cooler, and food scum buildup inside one of one commercial dishwashing machine.*Monitor and document the temperatures for one of one commercial dishwashing machine according to the provider's policy to ensure it reached the minimum rinse cycle temperature of 180 degrees for sanitization of dishes and equipment used to prepare and serve residents' meals.*Ensure safe food storage practices were [...]

Inspectors wroteBased on interview, document review, and policy review, the provider failed to ensure a water management program was in place to mitigate the growth and spread of Legionella (a type of bacterium commonly found in natural water sources). This had the potential to affect all residents, staff, and visitors within the facility.

Inspectors wroteA. Based on observation and interview the provider failed to ensure one of one sampled resident (32) had anything to eat or drink or had blood glucose monitoring within thirty minutes of receiving Novolog (a fast-acting insulin used to lower blood sugar) administered by licensed practical nurse (LPN) D.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure medications were securely stored and labeled for safe use according to professional standards to ensure:*One of one medication room was free from expired medical supplies.*Insulin pens for three of six sampled residents (7,12, and 32) were dated when removed from the refrigerator.*Five of five sampled residents (7,9,35,46, and 48) inhalers were dated when opened.*Two of two glucose test strip bottles were dated when opened.*Two of two medication carts were locked when unattended by two of two nurses (B and R).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (1) had a physician's order for supplemental oxygen when she was readmitted to the facility, and was provided continuous oxygen using a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) by the staff.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to incorporate one of one sampled resident's (9) Level II (2) Preadmission Screening and Resident Review (PASRR) into the Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment. Findings Include:1. Review of resident 9's electronic medical record (EMR) revealed she had a diagnosis of post-traumatic stress disorder (PTSD) and she was admitted to the facility on [DATE]. Her 11/11/25 MDS comprehensive assessment and 1/28/26 MDS quarterly assessment indicated that a PASRR Level II was not completed.2. Interview on 2/18/26 at 2:30 p.m. with social worker (SW) J revealed that the facility did not have a process to update the staff on if a PASRR Level II was completed for a resident. [...]

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the facility failed to ensure the safety for one of one sampled resident (48) who was identified at risk for elopement (leaving the facility without staff knowledge) and left the building unsupervised on 9/19/25.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure medical director EE attended and meaningfully participated in the provider's Quality Assurance and Assessment (QAA) meetings at least quarterly.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI] report, interview, record review and policy review the provider failed to prevent staff to resident sexual abuse from occurring for one of one resident (29).

Inspectors wroteBased on record review and interview the provider failed to ensure appropriate and timely Medicare notices had been provided for two of three sampled residents (47 and 250) who discharged from skilled services.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to follow physician orders for two of six residents (36 and 32) during medication administration that resulted in a medication error rate of 5.13%.

Inspectors wroteBased on interview, observation, and record review the provider failed to ensure room trays were served at a satisfactory temperature for three of thirteen sampled residents (30, 47, and 150) who chose to eat meals in their rooms due to the long wait time for meals to be served in the dining room.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to provide a bed-hold notice to the resident or their representative when transferred to the hospital for one of one sampled resident (26).

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 protect three of five sampled residents (2, 3, and 4) from mistreatment, intimidation, verbal abuse, and physical abuse by one of one certified nurse assistant (J).

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 resident property was not taken by one of one housekeeper (H) Failure to ensure the protection of resident property violated a resident's right to be free from misappropriation of resident property. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following notification of the incident.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to report allegations of abuse to the required entities in the required timeframe for two of two incidents of alleged abuse involving two of three sampled residents (3 and 4).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to investigate two of two reported allegations of abuse experienced by two of three sampled residents (3 and 4).

Inspectors wroteBased on interview, observation, and policy review, the provider failed to follow their policy to ensure a controlled medication (one easily diverted by staff) was securely stored for one of one (1) resident.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) had an investigation completed following falls with injuries.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) who had falls with injuries were reported to the South Dakota (SD) Department of Health after falls with injuries.

Inspectors wroteBased on record review and interview, the provider failed to ensure the proper Medicare notices were completed and provided for two of two sampled residents (8 and 48) who remained in the facility following their discharge from skilled services.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure narcotic medication had been reconciled correctly for one of one sampled resident (12).

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure one of five sampled residents (41) with a PRN (as needed) order for Seroquel had physician's documentation of the rationale for the continued use beyond the limited 14-day use.