Dells Nursing And Rehab Center Inc

F-F602 occurred on 11/24/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 1/16/25, the non-compliance is considered past non-compliance.

Review of education provided on 12/19/24 to all staff that administer medication revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0602 *Regulations for controlled substances require facilities have a system to account for controlled medication, receipt and disposition in sufficient detail to ensure accurate reconciliation. Level of Harm - Minimal harm or potential for actual harm *A shift-to-shift count is required to pass responsibility and accountability of controlled medication. Education was provided on 12/19/24 to all staff that administer medication regarding controlled medication regulations Residents Affected - Few and accountability of those medications, including liquid medications.

7. Education was provided on 12/19/24 to all staff that administer medication regarding controlled medication regulations and accountability of those medications, including liquid medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45383

Residents Affected - Few Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy

review the provider failed to report the missing controlled medication (medications with potential for abuse and addiction) had been reported timely to SD DOH.

Findings include:

1. Review of the provider's 12/4/24 SD DOH FRI revealed on 11/24/24 six milliliters (ml) of morphine sulfate (a controlled pain medication) had been unaccounted for.

2. Interview on 1/16/25 at 11:28 a.m. with nurse manager C regarding the reporting the missing controlled

medication revealed:

*She had not known the timeline requirement for reporting the missing controlled medication to SD DOH.

*She had not known that the missing medication could be considered theft of personal belongings.

*She had known that she had not followed the facility's policy for reporting the potential diversion of a controlled substance.

*On 11/25/24 she had begun the paperwork the pharmacy had provided her for drug diversion.

*The pharmacy had informed her that it was a misappropriation of a personal item on 12/4/24.

3. Interview on 1/16/25 at 12:16 p.m. with administrator A regarding the reporting of the missing controlled medication revealed:

*She had not been aware of the timeline for reporting missing medication to the SD DOH.

*Administrator A agreed that she had not followed their policy for reporting the potential diversion of a controlled substance.

Review of the provider's undated Reporting and Investigating Diversion of Controlled Substances Policy revealed:

*The investigation will be conducted with the assistance of human resources and will be completed within 48 hours of the incident's discovery.

*Severity of the theft or loss must be evaluated when considering reporting.

*Agencies to whom narcotic thefts may be reported include local office of [NAME] licensing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45383

Residents Affected - Some Based on observation, interview, record review, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for:

*Three of three sampled residents (4, 9 and 34) who had fallen.

*One of one sampled resident (7) who had a facility acquired pressure ulcer.

*One of one sampled resident (10) who had a history of urinary tract infections.

*One of one sampled resident (11) who developed a facility acquired pressure sore.

*One of one sampled resident (29) who had attempted to leave the facility without staff knowledge.

Findings include:

1. Review of resident 34's electronic medical record (EMR) revealed:

*She had fallen on 8/25/24, 10/12/24, and 12/28/24.

*On 12/28/24 resident 34 had an injury after her she fell and required a laceration repair above her left

eye in the emergency room .

*On 8/14/24 the care plan had identified her as at risk for falls.

Interventions on the 8/14/24 initiated care plan included a physical therapy evaluation to treat as needed and to follow the facility's fall protocol.

Interview on 1/15/25 at 2:00 p.m. with Minimum Data Set (MDS)/director of nursing (DON) B regarding interventions for resident 34 due to her falls revealed:

*She had an intervention for physical therapy (PT) to evaluate and treat as ordered initiated on 8/14/24.

*MDS/DON B stated that the facility's fall protocol was the same as their fall policy.

45683

2. Observation and interview on 1/14/25 at 8:26 a.m. of resident 10 while in her room revealed:

*She was sitting in her recliner working with an occupational therapist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 *Her goal was to get stronger and go to assisted living.

Level of Harm - Minimal harm or *She had been in the hospital recently for an infection. potential for actual harm

Review of resident 10's EMR revealed: Residents Affected - Some *She was admitted on [DATE REDACTED].

*Her diagnoses included:

-Chronic kidney disease, stage four.

-Type two diabetes mellitus without complications.

-Retention of urine, unspecified.

-History of urinary tract infection.

*Her 1/14/25 revised care plan had an intervention to monitor for signs and symptoms of infection, UTI (urinary tract infection) initiated on 3/27/24.

*She had orders for antibiotics to treat a UTI on 8/20/24, 8/21/24, 9/9/24, 10/21/24, 11/19/24, 12/6/24, and 12/16/24.

*No updates to the care plan were implemented regarding resident 10's UTIs since 3/27/24.

Interview on 1/16/25 at 10:05 a.m. with CNA G regarding resident 10's UTIs revealed:

*She had been instructed to watch for changes in her behavior that would indicate a UTI.

*She would report any changes to the charge nurse.

*If a UTI was suspected they would put a hat in her toilet to collect a urine sample.

*She did not have access to the residents' care plans.

Interview on 1/16/25 at 1:05 p.m. with MDS/DON B regarding resident 10's care plan revealed:

*The interdisciplinary team would review resident care plans and make changes as needed.

*If changes were made that information was communicated to staff in the pocket care plans (a print out of residents' basic needs for staff to follow).

*It was her expectation the care plans would be updated with any significant health issues that would arise.

*She agreed resident 10's care plan should have been updated to reflect her care needs related to UTIs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 50015

Level of Harm - Minimal harm or 3. Review of resident 29's electronic medical record (EMR) revealed: potential for actual harm *She had opened the front door and started to exit the facility on 12/14/24 at 3:35 p.m. Residents Affected - Some -Alarms sounded and alerted the staff.

-She was observed by registered nurse (RN) D standing in the doorway with her walker.

-She had been assisted back into the building by RN D.

-Her vital signs were taken, were within normal limit, and were documented.

*The incident was documented in her chart.

-Her family, provider, nurse manager C, and administrator A were notified.

*The Elopement Risk Tool completed by RN D on 12/14/24 at 3:50 p.m.

-Identified resident 29 was at risk for elopement

*Her diagnoses included:

-Vascular dementia (brain damage caused by multiple strokes) with psychotic disturbance.

-Adjustment disorder.

-Weakness.

-Hypertension.

*She had a Brief Interview for Mental Status (BIMS) assessment score of 12 which indicated she had moderate cognitive impairment.

-There was an order dated 12/31/24 to switch out monitors twice daily to recharge for safety monitoring.

*Her care plan did not indicate she was at risk for elopement.

-No interventions were indicated on her care plan following the above attempted elopement incident on 12/14/24.

Interview on 1/15/25 at 2:17 p.m. with registered nurse D revealed:

*She had started 30-minute visual checks on resident 29 following the above attempted elopement.

-They continued those checks for 24 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 -Then hourly visual checks were completed during the day.

Level of Harm - Minimal harm or -From 8:00 p.m. to 8:00 a.m. she would have been on 30-minute visual checks. potential for actual harm *She completed the Elopement Risk Tool on 12/14/24. Residents Affected - Some -That identified resident 29 as at risk for elopement.

*Care plans were to be updated by MDS/DON B.

*She was unsure if a tile alarm device was used on resident 29 following the incident.

Interview on 1/15/25 at 3:00 p.m. with MDS/DON B revealed:

*Regarding resident 29's elopement risk they would have considered her behaviors not the score on the assessment.

*On 10/18/24 her elopement risk score was 10, and she was not considered an elopement risk at that time.

*The elopement risk assessment score of 25 completed on 12/14/24, identified her as at risk for elopement.

*She agreed resident 29's care plan should have been updated after interventions were initiated.

*Nurse manager C and administrator A would decide on the use of tile device alarms. As an elopement prevention intervention.

*She agreed resident 29's care plan had not been updated to following the above attempted elopement or any interventions put in place.

Interview on 1/15/25 at 3:00 p.m. with administrator A and nurse manager C revealed:

*Resident 29 had used a tile device following the above incident on 12/14/24.

-Her family had approved and consented to the use of the device.

*They would have expected the care plan to have been updated following the elopement.

*Elopement education was provided to staff following resident 29's elopement on 12/14/24.

*Behavioral health had recommended memory care placement for resident 29.

50916

4. Observation on 1/14/24 at 9:09 a.m. with resident 4 in the dining room revealed:

*She was seated in her wheelchair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 *She had an electronic monitoring device on her wrist.

Level of Harm - Minimal harm or Review of resident 4's electronic medical record (EMR) revealed: potential for actual harm *She was admitted on [DATE REDACTED] Residents Affected - Some *She had a Brief Interview of Mental Status (BIMS) assessment score of 8, which indicated she was moderately cognitively impaired.

*Her diagnoses included cellulitis, dementia, and bulbous pemphigoid (an autoimmune disease that causes skin blisters).

*She had fallen on 8/9/24, 8/13/24, 8/14/24, 8/15/24, 8/28/24, 9/9/24, 10/10/24, 10/11/24, 10/13/24, and 12/18/24.

*She had an electronic monitoring device on her wrist that would alarm to alert staff of position changes as a fall prevention.

*There was no documentation of interventions in her care plan that addressed fall prevention since her admitted on 5/23/24.

5. Observation and interview on 1/14/24 at 10:35 a.m. with resident 9 in her room revealed:

*She was seated in her wheelchair listening to an audiobook.

*She had a full body mechanical lift sling underneath her.

*She had recently fallen.

*She used her walker for transfer assistance before she had fractured her ankle.

*She was transferred with the use of a full body mechanical lift and the assistance of two staff.

Review of resident 9's EMR revealed:

*She was admitted on [DATE REDACTED].

*She had a BIMS assessment score of 11, which indicated she was moderately cognitively impaired.

*Her diagnoses included chronic obstructive pulmonary disease, Parkinson's disease, and hypertension.

*She had fallen on 10/27/24, 10/28/24, 11/3/24, 12/9/24, 12/19/24, 12/20/24, and 12/22/24.

*There was no documentation of interventions in her care plan that addressed fall prevention since her admitted on 2/14/24.

Interview on 1/15/25 at 1:01 p.m. with registered nurse (RN) D revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 *MDS/DON B updated the residents' care plans and the pocket care plans.

Level of Harm - Minimal harm or *Hired agency workers and staff referred to the pocket care plans to help care for residents' needs. potential for actual harm

Interview on 1/15/25 at 3:28 p.m. with MDS/DON B regarding resident care plans revealed: Residents Affected - Some *She updated the resident's care plans and pocket care plans.

*She stated the care plans should be updated when a new intervention was added for a resident.

*She confirmed that residents 4 and 9 did not have new interventions documented on their care plans after their fall incidents.

*She confirmed the care plans should be updated to provide appropriate care for the residents' needs.

Interview on 1/16/25 at 8:32 a.m. with nurse manager C regarding resident care plans revealed:

*DON B was responsible for updating residents care plans.

*The interdisciplinary team (IDT) would meet daily at 10 a.m. to review resident falls that occurred during the night and discuss interventions to implement.

*Her expectation was that DON B would update and document the interventions in the residents' care plans

after the IDT meetings.

*She was not aware that fall interventions were not documented for residents 4 and 9 in their care plans.

*She had the capability to update the pocket care plans if it was needed.

51472

6. Observation and interview on 1/14/24 at 9:02 a.m. with resident 7 revealed:

*There were two cushions in her wheelchair.

*The top cushion was a waffle cushion that covered the bottom and back of the wheelchair.

*The cushion under the waffle cushion was a Roho cushion (air cushion that helps distribute weight evenly to prevent pressure ulcers).

*The Roho cushion was not inflated.

*Resident 7 transferred herself to her recliner.

*There was no cushion in the recliner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 *Resident 7 stated that her daughter brought her the waffle cushion for her comfort.

Level of Harm - Minimal harm or *She did not remember if she had any sores or skin problems. potential for actual harm

Review of resident 7's electronic medical record (EMR) revealed: Residents Affected - Some *She was admitted on [DATE REDACTED].

*Her 12/7/24 brief interview for mental status (BIMS) assessment was 12, which indicated moderate cognitive impairment.

*Her diagnoses included dementia, repeated falls, and weakness.

*She had a stage II pressure ulcer (a shallow open ulcer that resulted due to pressure) identified on 11/16/24.

*The stage II pressure was documented as healed on 12/6/24.

*She was prescribed mirtazapine with an Indication for Use: antidepressant.

*She did not have a diagnosis of depression.

Review of resident 7's 1/14/25 care plan revealed:

*She had a focus area of I have the potential to have impairment to skin integrity which was initiated on 5/30/24 and updated on 6/3/24.

*The use of the ROHO cushion or the waffle cushion was not included in the care plan.

*A focus area of I have a potential nutritional problem r/t [related to] hx [history] of CHF [congestive heart failure]; COPD [chronic obstructive pulmonary disease] and recent hip fracture with repair initiated on 7/8/24 included an intervention of Resident with stage II wound to left hip. Dislikes supplements. Will offer extra 1 oz [ounce] of protein with meals to aid in wound healing that was initiated on 12/6/24.

*A focus area of, I use antidepressant medication (mirtazapine) and interventions to:

-Administer ANTIDEPRESSANT medication as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT.

-Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs [problems], movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes

7. Observation and interview on 1/14/25 at 9:20 a.m. with resident 11 revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 *She was admitted to the facility after she fell and broke her hip.

Level of Harm - Minimal harm or *She stated she was mixed up. potential for actual harm *During the conversation resident 11 spoke with her eyes closed. Residents Affected - Some

Review of resident 11's EMR revealed:

*She was admitted on [DATE REDACTED].

*Her 10/7/24 BIMS assessment was 10, which indicated moderate cognitive impairment.

*Her diagnoses included: weakness, hallucinations, generalized anxiety, and dementia with psychotic disturbance.

*She was prescribed:

-lorazepam 0.5 mg (milligrams) every four hours as needed for anxiety or restlessness.

-olanzapine 5 mg two times per day related to dementia with psychotic disturbance.

Review of resident 11's care plan revealed:

*A focus area of, I use psychotropic medications (olanzapine) with interventions to:

-Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT.

-Monitor/document/report PRN adverse reactions to PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.

*Lorazepam or interventions to monitor for adverse effects was not referenced in resident 11's care plan.

*Non-phamalogical interventions relating to her hallucinations, anxiety, or psychotic disturbance, was not addressed in resident 11's care plan.

Interview on 1/15/25 at 3:28 p.m. with MDS/DON B revealed:

*She expected staff to follow the interventions on the residents' care plans.

*She was responsible for updating resident care plans.

*Care plan were to be updated when there were changes in resident care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 435129 Department of Health & Human Services Printed: 09/11/2025 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 435129 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dells Nursing and Rehab Center Inc 1400 Thresher Dr Dell Rapids, SD 57022

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 0657 *She agreed that resident 7's care plan was not updated to include her facility-acquired pressure ulcer.

Level of Harm - Minimal harm or Interview on 1/16/25 at 8:34 a.m. with nurse manager C revealed: potential for actual harm *She expected resident care plans to be updated to include pressure-reduction devices. Residents Affected - Some *She believed that the staff knew how to access resident care plans.

Interview on 1/16/25 at 10:21 a.m. with registered nurse (RN) D revealed:

*She had access to view resident care plans.

*She was not able to edit the care plans.

*Therapy [physical and occupational] was to be initiated for residents with pressure ulcers.

*If therapy placed ROHO cushions in residents' chairs they were to inform MDS/DON B to update the care plans.

*Nurse manager C worked with the pharmacist on the psychotropic medications.

*The charge nurse did not chart the side effects and effectiveness of the psychotropic and antidepressant medications.

Review of provider's 3/2024 Care Planning Process Policy revealed:

*Using an intradisciplinary approach, each resident will have an individualized plan of care which addresses

the resident's needs and severity of condition, impairment, disability, or disease and based on the universal care standards identified by the DNRC staff as the minimum standards for all residents.

*It is the responsibility of the IDT members to access the resident, individualize the plan of care, evaluate the effectiveness and the plan of care, revise the plan of care as the resident's needs change and attend care conferences.

Review of the provider's undated Fall Policy revealed:

*A licensed nurse will update the care plan to reflect interventions instituted to prevent further falls.

*The resident's fall will be discussed with interdisciplinary team as soon as possible after the falls to determine new interventions to try.

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