Strand-Kjorsvig Community Rest Home

Inspectors wroteBased on interview, observation, record review, policy review, and job description review the provider failed to ensure the facility was operated under the supervision of administrator A to ensure quality management and the overall well-being of all 26 residents in the facility.

Inspectors wroteBased on interview and policy review, the provider failed to ensure they had an effective quality assurance and performance improvement (QAPI) program that identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, or monitored regarding medication administration and storage, care plans, the completion of assessments, oxygen equipment use, trauma informed care, safe food storage, and infection control.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure the quality assessment and assurance (QAA) committee had included the required members of at least one of who was the administrator, owner, a board member, or other individual in a leadership role. The provider had no evidence of the administrator, owner, board member, or other designee having attended QAA meetings at least quarterly for 15 months of meeting attendance records reviewed (February 2024 through May 2025).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Four of four sampled residents (3, 8, 9, and 18) had been assessed to determine their ability to safely self-administer medications. *Three of four sampled residents (3, 9, and 18) had a physician's orders to self-administer those medications as directed in the provider's policy. Findings Include: 1. Observation and interview on [DATE] at 1:39 p.m. and 1:57 p.m. with resident 9 in his room revealed: *There was a nebulizer machine (a machine that converts liquid medication into an inhalable mist) on the floor to the left of his recliner. *He sat in his recliner and held his nebulizer mask to his face to administer the medication. *He reached down and shut off that nebulizer machine, then turned it back on when the surveyor stated she would return. [...]

Inspectors wrote3. Observation and interview on 5/6/25 at 8:55 a.m. with resident 79 in her room revealed she: *Could not remember the exact date she was admitted , but she knew it was in March 2025. *Had been in and out of the hospital at least two times since she was admitted due to blood loss. *Did not know what a care plan was. Review of resident 79's EMR on 5/7/25 revealed: *She was admitted on [DATE]. *Her 3/10/25 BIMS assessment score was 10, which indicated she was moderately cognitively impaired. *Her baseline care plan had been initiated on 3/3/25 but was not completed. *The baseline care plan was labeled 'Errors in the EMR. *There were no progress notes that indicated a baseline care plan was reviewed or given to the resident or her representative. [...]

Inspectors wrote5. Observation and interview on 5/5/25 at 4:07 p.m. with resident 7 in his room revealed: *He was sitting in his recliner. *He was not sure if he had been offered counseling sessions. *His biggest concern at that time was the food he was being served. Review of resident 7's EMR revealed: *He was admitted on [DATE]. *His 3/31/25 BIMS assessment score was 11, which indicated he was moderately cognitively impaired. *His diagnoses included: -Post-traumatic stress disorder (PTSD), unspecified. -Delirium due to a known physiological condition. -Personal history of other mental and behavioral disorder. -Major depressive disorder, recurrent, severe with psychotic symptoms. Review of resident 7's 4/1/25 care plan revealed: *He had a focus area of, an ADL [activities of daily living] self-care performance deficit r/t [related t]) delirium/depression/PTSD. [...]

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure: *A physician-ordered Abnormal Involuntary Movement Scale (AIMS) assessment was completed and the results were communicated for one of one sampled resident (19) who received an antipsychotic medication. *The physician was notified of one of one sampled residents' (25) insulin having been held related to low blood sugars.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential theft) to ensure accurate counts and complete documentation of those medications in one of one medication cart and one of one refrigerators that contained controlled medications.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure: *Medications with shortened expiration dates [medications that, after opening, expire prior to the manufacturer's expiration date] were labeled properly and disposed of after having outdated for three sampled residents (3, 14, and 79) and one random resident (24) in two of two medication carts and one of one treatment cart. *Daily temperatures of one of one refrigerator containing medications were monitored and document according to the provider's policy for twelve of twelve months reviewed in 2024 and two of two months (March and April) in 2025. *Daily temperatures of one of one area used to store medications was monitored and documented according to the provider's policy. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure enhanced barrier precautions (EBP) were followed according to the provider's policy for two of two sampled residents (25 and 79) on EBP.

Inspectors wroteBased on interview, policy review, and record review, the provider failed to implement an effective antibiotic stewardship program according to their policy related to: *Ensuring residents' symptoms were present and documented prior to contacting their physicians related to potential infection. *Reviewing infections and antibiotics for possible trends. *Completing and annual summary of antibiotic use in the facility and reporting that to the QAPI committee. *Having an antibiogram (a table that shows which antibiotics are most likely to be effective against specific bacteria) done every 18-24 months to guide development or revision of antibiotic use protocols. *Following up annually with physicians regarding antibiotic use for residents.

Inspectors wroteBased on interview, and record review, the provider failed to ensure that one of one designated infection preventionist (director of nursing C) had completed specialized training in infection prevention and control.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure: *Proper infection control practices had been followed for cleaning and storage for two of two sampled residents (9 and 25) who required respiratory devices (Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open) and a nebulizer), had appropriate cleaning and storage. *One of one sampled resident (25) receiving oxygen at night had a current physician order for use of a CPAP machine, and was care planned.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to assess two of two sampled residents (7 and 14) who had a diagnosis of post-traumatic stress disorder (PTSD) for their potential needs and interventions relating to trauma.

Inspectors wroteBased on observation, interview, and policy review the provider failed to follow acceptable food safety practices by not having ensured that food packages were dated when opened and outdated food items were discarded from inventory in one of one observed kitchen.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (1) by staff who did not observe the resident take her medications after preparting them, which enabled the resident to not ingest multiple doses, hide those medications in her room, and then ingest those medications all at once as an act of self-harm.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, record review, interview, and policy review, the provider failed to follow their medications administration policy and correctly administer medication to one of one sampled resident (1) who required hospitalization after a self-harm incident. Staff were not ensuring her medications were consumed during the administration process.

Inspectors wrote10. Observation and interview on 1/3/23 at 8:25 a.m. with resident 17 revealed: *His bed had two quarter bed rails in the raised position. *He had used the bed rails for repositioning in bed and to assist him in sitting up. Review of resident 17's EMR revealed: *On 11/22/22 a physician ordered May have bilateral quarter bed rails for body positioning/transferring/bed mobility. *His 10/23/23 Bed Rail/Assist Bar Evaluation stated that the resident used the bilateral half bed rails for bed mobility, repositioning, and getting in and out of bed. The bed rails assisted him to maintain his mobility. The MDS for resident 17 was signed on 10/23/23 at 2:00 p.m. and coded as a restraint for daily use by MDS coordinator D. 11. Observation and interview on 1/3/23 at 9:38 a.m. with resident 23 revealed: *He was lying in bed with two half bed rails in the raised position. [...]

Inspectors wroteBased on record review and interview, the provider failed to ensure the proper Medicare notices were completed and provided for one of three sampled residents (2) prior to discharge from skilled services.

Inspectors wroteBased on observation, record review, and interview the provider failed to ensure an individualized care plan for one of one sampled resident (23) who had a pressure ulcer had been developed, reflecting identified interventions and implementation and evaluation of them.

Inspectors wrote2. Review of resident 22's electronic and paper medical record revealed: *There was a change in skin notification sent to resident 22's primary care provider on 11/5/22 regarding blisters on his fingers. *The note read, Resident has large blister on [left] pinky finger and small popped blister on [left] ring finger. Blisters cleaned [with] soap [and] water. Triple [antibiotic ointment] placed on popped blister [and] covered [with] bandaid. Pinky blister covered loosely. Resident stated blister came from hot pizza. Review of resident 22's care plan revealed: *A new focus area of Risk for Injury/burns as I have decreased sensation to my fingers and toes. I drink coffee and my potential for spilling it was added on 11/7/22. *The goal read as follows: I will not receive any burns/blisters from hot liquids/foods through next review. [...]

Inspectors wroteBased on observation, interview record review, and policy review, the provider failed to develop a comprehensive person-centered care plan regarding respiratory care for 1 of 13 sampled residents' (16) care plans reviewed.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to revise 1 of 13 sampled residents' (2) care plans reviewed after a significant change assessment had been completed to accurately reflect the current status of the resident.