F-F851. Residents Affected - Many
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food
in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45383
Residents Affected - Many Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure one of one kitchen had been cleaned to maintain a sanitary environment to store, prepare, and serve food to residents. Multiple areas within the kitchen appeared unclean.
Findings include:
1. Observation on 5/18/25 at 11:30 a.m. of the kitchen revealed:
*The plate storage cabinet had dust on top of the cabinet where the plate covers were stored.
*The shelves where the dishes had been stored had food debris and stains on the shelves.
*The beverage serving cart with prepared residents' beverages on it had food debris and food stains on the shelves.
*The kitchen floor, under the stove, and storage racks were soiled with food debris and dirt.
*Drawers containing clean utensils had food stains and food debris in them.
*The recessed cabinet and drawer handles were soiled with food debris.
*The refrigerator door was soiled food debris.
2. Interview on 5/18/25 at 11:50 a.m. with dietary aide M regarding the cleaning of the beverage storage cart revealed the cart should have been cleaned after every use.
3. Interview on 5/18/25 at 1:00 p.m. with cook L regarding the cleaning of the plate storage cabinet revealed:
*The cooks had specific cleaning scheduled tasks for kitchen equipment and the dietary aides had specific cleaning scheduled tasks for the kitchen.
*She agreed the plate storage cabinet was not clean, and she was unsure of the last time it had been cleaned.
4. Interview on 5/20/25 at 9:15 a.m. with cook N regarding the kitchen cleaning tasks schedule revealed:
*There was a task to clean the inside and outside of the cabinet doors by the cooks.
*She tried to keep up with the cleaning of the inside of utensil storage drawers.
*Everyone should have cleaned the drawers if they had noticed they were dirty.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 *She had agreed that placing clean utensils in a dirty drawer would not be sanitary.
Level of Harm - Minimal harm or 5. Interview on 5/21/25 at 1:30 p.m. with dietary manager (DM) K regarding the cleaning of the kitchen potential for actual harm revealed:
Residents Affected - Many *All staff who worked in the kitchen were responsible for cleaning the kitchen if they had noticed something was unclean.
*She agreed there was no scheduled kitchen cleaning task for the inside of drawers and cabinets.
*She agreed the cabinet, drawer, and refrigerator handles were unclean.
*DM K agreed that if the floors had been observed as dirty, then the cleaning had not been completed.
Review of the provider's May 2022 Sanitation and Cleaning schedules revealed:
*It will be the responsibility of the dietary manager (DM) to provide daily, weekly, monthly, and as necessary cleaning schedules in the dietary areas.
*Each dietary staff person will be responsible for knowing his or her assigned duty and carrying it our during
the designated work schedule.
*The DM is responsible for monitoring staff to ensure that cleaning duties are completed satisfactorily and within proper time frames.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 51370
Residents Affected - Many Based on interview and review of Certification and Survey Provider Enhanced Reports (CASPER) reporting data, the provider failed to ensure their Payroll Based Journal (PBJ) (information of the providers daily staffing hours for the appropriate care of the resident)s had been complete and the data had been submitted to the Center for Medicare and Medicaid Services (CMS) for the months of May and June in Quarter 3 of FY 2024.
1. Review of the provider's CASPER reporting data revealed that PBJ data submitted for the following dates
in Quarter 3 2024 demonstrated the provider failed to ensure Licensed Nursing Coverage 24 hours per day:
-May 1 through 31 for a total of 22 days.
-June 1 through 30 for a total of 21 days.
Interview on 5/21/25 at 11:00 a.m. with emergency permit holder administrator A (EPH administrator A) revealed:
*She was hired at the facility on 1/20/25.
*She was aware that the previous administrator who left at the end of December 2024 had not submitted PBJ data or had submitted it incorrectly.
*She was not able to document through payroll data that they facility had 24 hours of licensed nursing coverage on the above dates as DON B was responsible for covering any shifts to ensure they met this requirement.
*DON B was a salaried employee and had not been required to keep any record of hours worked.
Interview on 5/21/25 at 11:15 a.m. with DON B revealed:
*She was aware that the provider had previously failed to submit PBJ data.
*She was responsible for covering any shifts to provide 24 hours of licensed nursing coverage.
*She did not keep any record of days and hours worked and was not required to punch the timeclock.
Review of the payroll data and work schedules provided by the facility on 5/19/25 revealed:
*Schedules for May and June 2024 showed DON B was scheduled for one floor shift per week.
*Payroll data confirmed 24 hours of nursing coverage on 5/9/24, 5/10/24, 5/17/24, 5/18/24.
*Employee schedules were not auditable (not able to be verified).
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851 Review of provider's April 2023 payroll based journal submission procedure policy revised in May 2024 revealed: Level of Harm - Minimal harm or potential for actual harm *Mandatory submission of staffing information based on payroll data in a uniform format.
Residents Affected - Many *The procedure steps were:
-Direct care staffing and census will be collected quarterly and is required to be timely and accurate. Staffing data includes the number of hours paid to work by each staff member each with day within the quarter.
-Fiscal quarters were Q1: October 1-December 31, Q2: January 1-March 31, Q3: April 1-June 30, Q4: July 1-September 30.
-Ensure all data is accurate and timely, submit electronically to CMS each quarter.
-Run validation report to ensure the upload was accepted.
-Run 1705D Staffing Data Report to confirm no triggers and all staffing requirements are met.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51370 potential for actual harm Based on observation, interview, and policy review, the provider failed to ensure staff followed proper Residents Affected - Many infection control practices regarding:
*The cleaning of shared resident equipment by two of two observed certified nursing assistants (CNA) (R and T).
*Hand hygiene between assisting residents during an observed meal service of one of one CNA (R).
*Protecting clean linens from potential contamination during transport by one of one observed CNA (U).
*Hand hygiene while changing water mugs for residents by one of one observed dietary aide (Q).
*Cleaning and sanitizing the whirlpool tub and chair by two of two CNA's (S and T).
*Followed enhanced barrier precautions (EBP) (requires use of gown and gloves with contact care for three of three identified residents (1, 5, and 25).
Findings include:
1. Observation on 5/18/25 at 10:19 a.m. revealed:
*Certified nursing assistant (CNA) T pushed a stand aid from an unidentified resident's room on the 300 hall.
*An unidentified CNA then took that stand aid to another resident's room on the 300 hall. No cleaning of the equipment occurred.
Observation and interview on 5/20/25 at 9:36 a.m. of CNA R returning a mechanical lift (lift and sling used to lift a person's full body) from a resident's room on the 300 hall revealed:
*She had not cleaned the lift after using it in a resident's room.
*They were supposed to clean the shared equipment, such as lifts, between each resident use, but that only occurred with the equipment was visibly dirty or they had time to clean it.
*When asked about the cleaning process, she pointed to sanitizing wipes located at the nurses' station and stated after cleaning the equipment of any visible dirt, they are to re-wipe the equipment with a clean sanitizing wipe.
Interview on 5/20/25 at 10:25 a.m. with CNA T regarding the cleaning of shared resident equipment revealed staff were to clean the equipment when they were visibly dirty with the sani-wipes located at the nurse's station.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Observation of the Super Sani-cloth sanitizing wipes label instructions revealed to keep the surface wet for
the entire two minutes to allow the active ingredients enough time to interact with and kill microorganisms. Level of Harm - Minimal harm or potential for actual harm Interview on 5/20/25 at 3:14 p.m. with Minimum Data Set (MDS) Coordinator C revealed:
Residents Affected - Many *Staff were trained at orientation and annually to clean the lift equipment between each resident use with a sani-wipe.
2. Observation on 5/18/25 at 12:24 p.m. of CNA R in the dining room as she was seated at a table between two residents that needed full assistance with eating revealed:
*She got up from the table and used her hands and arms to assist another staff member lift a resident in their wheelchair.
*She returned to the table and continued to assist the two residents with eating without washing or sanitizing her hands.
Interview on 5/20/25 at 9:36 a.m. with CNA R revealed:
*She was trained on assisting residents with eating during her orientation.
*She confirmed she had not completed hand hygiene after having close contact with another resident before
she assisted other residents with eating as observed above.
*She should have had hand sanitizer at the table and used it between assisting the residents.
Interview on 5/20/25 at 3:14 p.m. with MDS Coordinator C revealed:
*Staff were trained on proper hand hygiene during their orientation and annually.
*Hand hygiene should have been completed between tasks and resident contact.
3. Observation and interview on 5/20/21 at 2:51 p.m. with CNA U in the 100 hall and 200 hall revealed:
*She had been restocking towels in resident rooms from a portable linen cart.
*She was moving the cart through the hall and day room space without the cover in place.
*She stated she was supposed to keep the cover over the linens.
*She stated she would close the cover of the cart when she stocked linens in the room of a particular resident who had a communicable disease.
Interview on 5/20/25 at 3:14 p.m. with MDS Coordinator C revealed she expected the linen carts to be covered at all times, including when transporting between rooms and through a common area of the facility to protect the linens from potential contamination.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Review of the provider's 2/28/24 document titled policies and procedures for laundry revealed the transportation of linen and laundry shall be completed with the clean linen storage containers and racks and Level of Harm - Minimal harm or covered at all times. potential for actual harm 4. Observation and interview on 5/20/25 at 9:34 a.m. with dietary aide Q revealed: Residents Affected - Many *She was delivering fresh water mugs to resident rooms on the 300 hallway.
*She had a cart with the clean water mugs and a separate cart where she placed the dirty mugs as she removed them from the resident's rooms.
*She took a clean mug into the resident's room and returned with the dirty mug.
*She did not complete any hand hygiene between handling the clean mugs and the dirty mugs or between resident rooms.
*She reported she had received infection control and hand washing education at their staff meetings.
*Her education for passing residents' water mugs was to use separate carts, one for clean mugs and one for dirty mugs.
*She was not aware that she should have washed her hands between handling the clean and the dirty mugs.
Interview on 5/20/25 at 3:00 p.m. with dietary manager K revealed:
*She had recently completed the ServSafe for Food Managers training.
*She had not made any changes to the staff's water mug pass process for residents since she started on 9/12/24.
*She did not provide any regular training for dietary staff.
*Her orientation process for new staff was to work with them for a few days.
*She agreed that the current water mug pass process was not sanitary.
Review of the provider's 5/2/24 water pass policy revealed:
*The purpose was to provide guidelines for staff and volunteers to ensure contamination does not happen when passing fresh water.
*The procedure steps included:
-Take gray (dirty) cart around to collect all dirty mugs from resident rooms and bring to dishwashing room.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 -Wash hands using hand hygiene procedure.
Level of Harm - Minimal harm or -Take water pass cart around to resident rooms. potential for actual harm 5. Observation and interview on 5/20/25 at 10:28 a.m. with CNA T in the shower room revealed: Residents Affected - Many *She worked as the bath aide approximately one day per week.
*She cleaned the whirlpool tub and chair by:
-Moving the chair into the whirlpool tub.
-Filling the tub with water.
-Measuring about a half cup of sanitizing disinfectant in a disposable cup and adding it to the water.
-Turning on the whirlpool jets and letting them run for about five minutes.
-Draining the tub and rinsing it with the spray wand.
*She stated she followed that process when she had completed all of the baths for the day.
*In between baths, she would spray the tub and chair with Clorox disinfecting spray, rinse, and dry the chair with a towel.
*She did not recall who had trained her on those cleaning techniques.
Observation and interview on 5/21/25 at 8:55 a.m. with CNA S revealed:
*She cleaned the whirlpool tub and chair by spraying them with the Clorox disinfecting spray, scrubbing them with a towel, let them sit for a few minutes, then sprayed them off with water.
*She would wipe the chair seat dry with a towel.
*She cleaned the chair legs after all baths had been completed.
*She preferred the bleach product above and did not use the sanitizing disinfectant chemical provided by the facility.
*She had learned to clean the whirlpool tub and chair from other CNAs.
Observation of the tub chair revealed:
*The paint on the chair legs was completely chipped away at each end of the legs.
*The exposed metal surface was rusted and was an uncleanable.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Interview on 5/20/25 at 3:14 p.m. with (MDS)Coordinator C revealed:
Level of Harm - Minimal harm or *She was responsible for ensuring the whirlpool tub cleaning process was followed by staff. potential for actual harm *She was not aware there was a Clorox disinfecting spray in the tub room. Residents Affected - Many *The policy directed staff to use the provided sanitizing disinfectant after every resident bath for proper cleaning and disinfection of the tub.
Review of the provider's 2/28/25 policy and procedures for cleaning of the whirlpool tub and shower chair revealed the cleaning procedure steps were:
- Place chair in the tub, close and lock the tub door.
-Press the tub fill button and turn the temperature control knob all the way to the left to its warmest level to heat the disinfectant solution and maximize its effectiveness.
-Remove residue by rinsing the inside tub surfaces with water using the sprayer.
-Press the fill button again to turn off the water.
-Using premixed Classic whirlpool disinfectant and cleaner in a spray bottle, thoroughly spray the interior of tub and chair.
-Use the button on the side of the tub to run disinfectant through the outlets.
-Use the long-handled brush to scrub all interior surfaces of the tub and chair.
-Let the disinfectant stay visibly wet on the surfaces for 10 minutes.
-Remove the plug from the drain.
-Spray water from the shower sprayer into both outlets until clear water appears from the inlet.
-Visibly check that the tub and chair were effectively cleaned during the disinfecting process. If not, repeat procedure.
-At the end of the day, use a towel to wipe off all excess water in tub and chair.
*The whirlpool tub and shower chair were to be disinfected with the above procedure after each resident use.
6. Observation and interview on 5/19/25 at 12:48 a.m. with resident 5 in his room revealed:
*He had a suprapubic catheter (tube surgically placed in the bladder through the abdomen to drain urine) and a colostomy.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 *There was a rack on the inside of the partially opened bathroom door containing personal protective equipment (PPE). Level of Harm - Minimal harm or potential for actual harm *He stated that staff used the gloves when they emptied his catheter and changed his colostomy bag.
Residents Affected - Many *Staff wore gowns sometimes when emptying the catheter bag and providing his personal cares, but not always.
*There was a sign inside the bathroom door that EBP (requires use of gown and gloves with contact care) was required.
Review of resident 5's care plan revealed:
*A focus area of I have Suprapubic Catheter: Neurogenic bladder. Skin breakdown that was initiated on 2/23/21 and revised on 3/3/21.
*The interventions included My SP [suprapubic] catheter requires little care.
*There was no documentation for the use of EBP while providing his catheter bag emptying or his catheter cares.
Review of resident 5's Electronic Medical Record (EMR) revealed:
7. Observation and interview on 5/18/25 at 11:00 a.m. with resident 25 in his room revealed:
*He had an indwelling catheter (a tube placed in the bladder to drain urine).
*Staff used gloves when emptying the catheter bag and providing his catheter care.
*He did not think staff had worn gowns when completing those tasks.
*There was no signage in his room that indicted he was on EBP.
Review of resident 25's care plan revealed:
*A focus area of I have an Indwelling Catheter r/t surgery of the foreskin r/t [related to] (Balanitis) initiated on 3/21/25.
*Interventions included catheter care every shift per facility protocol.
*There was no documentation in his care plan for the use of EBP while providing his catheter bag emptying or his catheter cares.
*There was no signage in his room indicating that EBP should be used when providing catheter cares.
Interview on 5/20/25 at 9:19 a.m. with CNA R revealed:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 *She provided care for residents 5 and 25.
Level of Harm - Minimal harm or *She described the correct process for putting on PPE when emptying the catheter urine bag or providing potential for actual harm cares.
Residents Affected - Many *She wore gloves but did not always use PPE when emptying or providing cares.
*She would not use PPE when helping resident to transfer with the lift.
Interview on 5/21/25 at 3:14 p.m. with MDS Coordinator C revealed:
*She had not included the use of EBP on residents' care plans.
*She did not know she should have included it on residents' care plans.
*She thought staff would know to use EBP for some residents because they had a meeting when the new EBP standards were implemented, and they covered it at their mandatory annual staff training.
*She felt new staff would know how to use EBP because they work with one of the registered nurses (RNs) for several shifts and the RNs would educate them.
*She was not aware of any signage available to post to inform staff or visitors of the need for use of EBP.
*They did not have an infection control policy but she had a binder of information she had printed that she had found online.
Review of the provider's 4/2025 revised catheter care, leg bag/catheter bag cleaning and storage policy revised revealed:
*Procedural steps that included:
-Assemble equipment.
-Wash hands.
-Five steps for disconnecting, using alcohol swabs, cleaning bag, draining, drying, and storage.
-Wash hands.
*Key Points listed were:
-to prevent cross-contamination
-to maintain Drainage system
-observations of urine
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 -to remove excess urine and minimize bacterial growth, contamination. Do not allow tip of bag to come in contact with any surface. Level of Harm - Minimal harm or potential for actual harm *It did not address the use of EBP.
Residents Affected - Many Review of the provider's untitled policy and procedure revised 12/5/24 regarding maintaining a closed system
on all indwelling urinary drainage systems as much as possible and decrease the possibility of catheter associated urinary tract infections revealed:
*The listed purpose was Maintaining a closed system on all indwelling urinary drainage systems as much as possible and decrease the possibility of catheter associated urinary tract infections.
*The procedure steps included Correct hand hygiene and Standard Precautions (or appropriate isolation) to be utilized by all trained staff handling and maintaining catheters.
50015
8. Observation and interview on 5/19/25 at 1:09 p.m. with resident 1 in his room revealed:
*He had a suprapubic catheter (a tube surgically placed in the bladder through the abdomen to drain urine).
*He had wounds to his coccyx (tailbone) and buttock.
*There was no personal protective equipment (PPE) such as gowns, available for use in his room.
*He stated staff wore gloves, but no gowns when they emptied his catheter and when completing his wound care.
*There was no signage in his room for enhanced barrier precautions (EBP).
9. Review of resident 1's electronic medical record (EMR) revealed:
*He was admitted on [DATE REDACTED].
*His Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated he was cognitively intact.
*He had acquired a wound on 3/3/25 to his right inner gluteus (buttock) fold.
*He had acquired a wound on 3/3/25 to his coccyx (tailbone).
*He had a suprapubic catheter that was to be changed every two weeks.
10. Interview on 5/20/25 at 4:04 p.m. with licensed practical nurse (LPN) D revealed:
*She received education on using EBP for resident's 1 and 5.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 *Staff knew which residents required the need to wear gowns for cares such as, catheter, and wound care.
Level of Harm - Minimal harm or *Changes in residents' care needs are passed along during change of shift report. potential for actual harm
Interview on 5/20/25 at 4:07 p.m. with Minimum Data Set (MDS) Coordinator C revealed: Residents Affected - Many *Resident 1 had Osteomyelitis, and she did some research which stated resident 1 did not need to be on EBP.
*EBP should be included in the care plan for residents with wound care and catheter care needs.
Interview on 5/21/25 at 7:24 a.m. with emergency permit holder (EMP) administrator A revealed the provider does not have a EBP policy.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in
the nursing home. Level of Harm - Minimal harm or potential for actual harm 51370
Residents Affected - Many Based on interview and record review, the provider failed to ensure that one of one designated infection preventionist Minimum Data Set (MDS) coordinator C had completed specialized training in infection prevention and control as required by the Centers for Medicare and Medicaid Services (CMS).
Findings include:
1. Interview on 5/18/25 at 3:14 p.m. with MDS coordinator C regarding the infection prevention and control program (IPCP) revealed:
*She was a licensed practical nurse (LPN) and the designated infection preventionist (IP).
*She had been hired by the facility on 11/30/2019.
*She was a full-time employee and was responsible for MDS coordination, resident care plan development, restorative therapy, and the IPCP.
*She worked two scheduled nursing shifts on the floor per week along with the above duties.
*She had not completed the course test required to obtain the IP certification.
*She had expressed to the previous administrator that she felt she had too many work responsibilities and was unable to complete the test.
*She believed the leadership team was going to get someone else to be the designated infection preventionist in her place.
Interview on 5/20/25 at 10:30 a.m. with director of nursing (DON) B revealed:
*MDS coordinator C had completed all of the training modules to required to take the certification test.
*MDS coordinator C had not completed her infection preventionist certification test.
*She believed that MDS coordinator C had exceeded the time requirement to take the certification test and
she would not be able to take the test without completing the training course again.
*She was hoping that a recently hired LPN would consider taking over the IP duties for the facility.
Interview on 5/21/25 at 11:00 a.m. with emergency permit holder (EPH) administrator A revealed:
*She was hired as an EPH administrator on 1/20/25.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 435088 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435088 B. Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Centerville Care and Rehab Center Inc 500 Vermillion St Centerville, SD 57014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0882 *She was aware that MDS coordinator C had not completed her IP certification.
Level of Harm - Minimal harm or *EPH administrator A stated she was responsible for ensuring the training requirement was met. potential for actual harm
Review of the training module certificates for MDS coordinator C revealed there was no certificate that Residents Affected - Many indicated she had completed the required training.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 435088