Seven Sisters Living Center

F-F755 occurred on 6/11/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 7/25/24, the non-compliance is considered past non-compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 435072 Department of Health & Human Services Printed: 09/17/2025 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 435072 B. Wing 07/25/2024

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

Seven Sisters Living Center 1201 Hwy 71 South Hot Springs, SD 57747

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 42558 potential for actual harm Based on South Dakota Department of Health (SD DOH) complaints report review, interview, and record Residents Affected - Few review, the provider failed to correctly administer narcotic (pain relieving) medications as ordered for two of two sampled residents (1 and 15). Failure to administer narcotic medications as ordered may have contributed to residents 1 and 15 having increased pain, discomfort, and side-effects of narcotic withdrawal.

This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the discovery of the medication errors.

Findings include:

1. Review of the two 6/27/24 SD DOH complaint reports revealed:

*Resident 1 had not received her Fentanyl (a controlled medication for severe pain) medication as ordered by her physician.

-She was supposed to have received a new Fentanyl topical patch every 72 hours (3 days).

*Her Fentanyl patch was applied on 6/8/24.

-It had not been replaced from 6/8/24 through 6/21/24.

*She did not receive four doses.

-She had increased pain and migraine headaches during that time.

*She had called a friend and was reported to have been crying because of her increased pain and migraine headaches.

2. Interview on 7/23/24 at 9:23 a.m. with resident 1 revealed:

*She was receiving hospice care for end-stage kidney failure.

*She stated, I started having pain and looked at the calendar and found out it (Fentanyl patch) hadn't been changed in several weeks. It was supposed to be changed every three days.

-She stated she had increased back pain and severe migraine headaches during that time.

-She stated, It was a doozy for a few days. It was a hell of a migraine.

*She stated a hospice nurse told her the Fentanyl patch medication was prescribed correctly to indicate it would be replaced every 72 hours (three days), but the pharmacy had changed it to be replaced every 72 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 435072 Department of Health & Human Services Printed: 09/17/2025 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 435072 B. Wing 07/25/2024

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

Seven Sisters Living Center 1201 Hwy 71 South Hot Springs, SD 57747

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 0760 *She stated that while a nurse was speaking to her about the medication error, an aide was also in her room and informed her there was another resident (15) who had the same problem with her Fentanyl patches. Level of Harm - Minimal harm or potential for actual harm -She stated resident 15 had dementia and was unable to communicate her needs and she was worried about medication errors happening to other residents who were unable to defend themselves. Residents Affected - Few 3. Review of resident 1's electronic medical record (EMR) and June 2024 medication administration record (MAR) revealed:

*She had received hospice services that had begun in April of 2024 for stage 5 renal failure.

*She had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

*She had an order for: Fentanyl Transdermal Patch 25 mcg/hr [micrograms per hour]. Apply 1 patch every three days. Remove patch after 72 hours (3 days) and fold in half and dispose of according to facility procedures.

-Her MAR indicated the Fentanyl order had been changed on 6/8/24 to Apply one patch transdermally one time a day every 72 days.

*She had a new patch applied on 6/8/24 and it had not been replaced until 6/21/24. Four applications were missed over thirteen days.

4. Review of resident 15's EMR and May 2024 MAR revealed:

*She was on hospice care for terminal breast cancer.

*She had a BIMS score of 4, which indicated she had severe cognitive impairment and was non-interviewable.

*She had an order for: Fentanyl Transdermal Patch 25 mcg/hr. Apply 1 patch transdermally one time a day every 72 hours.

-Her May 2024 MAR indicated the Fentanyl order had been changed on 5/9/24 to state Apply one patch transdermally one time a day every 72 days.

-She had a new patch applied on 5/9/24 and it had not been replaced until 5/16/24, missing two applications over seven days.

5. Interview on 7/23/24 at 3:24 p.m. with licensed practical nurse (LPN) H and LPN I revealed:

*The pharmacy entered medication orders into the EMR's MAR in Point Click Care (PCC).

-If the pharmacy was closed, the nurse would have entered the order into PCC and the order would have been verified by the night nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 435072 Department of Health & Human Services Printed: 09/17/2025 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 435072 B. Wing 07/25/2024

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

Seven Sisters Living Center 1201 Hwy 71 South Hot Springs, SD 57747

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 0760 6. Interview on 7/25/24 at 9:00 a.m. with assistant director of nursing (ADON)/resident care manager C revealed: Level of Harm - Minimal harm or potential for actual harm *The Fentanyl orders had been entered into PCC incorrectly and indicated staff were to have applied a patch every 72 days and not every 72 hours as prescribed. The MARs on the computer only showed what was to Residents Affected - Few be given each day, according to what had been entered into PCC, so those Fentanyl orders had not appeared on the daily MAR screen to be given and were missed.

*She stated that when the Fentanyl medication errors had been identified, pharmacist F implemented two secondary order verification systems.

-All medication orders were verified by a second person in the pharmacy and a MAR was printed to verify the accuracy of new orders.

-All Fentanyl orders had a daily patch monitor prompt to be signed off on the daily MAR which was separate from the MAR's Fentanyl order.

*She was included in all the pharmacy medication error reports and medication errors were reviewed by the pharmacy and nursing administration every week. They were also reviewed by a multidisciplinary team

during the monthly quality assurance and safety meetings.

-All medication aides and nurses were educated on the new Fentanyl patch monitoring process on 7/1/24.

7. Interview on 7/25/24 at 10:30 a.m. with pharmacist F regarding the above findings revealed:

*The physicians would enter their orders in an EMR system called EPIC and the pharmacy staff would enter those orders into PCC.

*Both Fentanyl orders were entered incorrectly by pharmacist X. When that repeated medication error was discovered, the two-party verification, printing of MARs, and daily patch monitoring systems were implemented.

*The pharmacy had increased the monitoring of medication errors from monthly to weekly and included nursing administration, quality assurance, and the safety team, in all reports.

*He stated the quality assurance and safety team had been discussing the re-implementation of a medication error committee for increased focus on medication and documentation errors.

The provider's implemented systemic changes to ensure the deficient practice does not reoccur was confirmed on 7/25/24 after record review revealed the facility had followed their quality assurance process, education was provided to the pharmacy and nursing staff regarding the two-person order verification process, pharmacy printing and double checking the MARs for correctness, daily monitoring of resident's Fentanyl patches, and a review of the medication error report revealed no further Fentanyl medication errors had occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 435072 Department of Health & Human Services Printed: 09/17/2025 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 435072 B. Wing 07/25/2024

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

Seven Sisters Living Center 1201 Hwy 71 South Hot Springs, SD 57747

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 0760 Based on the above information, non-compliance at

F-F760 occurred from 5/9/24 through 5/16/24 and again from 6/8/24 through 6/21/24, and based on the provider's implemented corrective actions for the deficient Level of Harm - Minimal harm or practice confirmed on 7/25/24, the non-compliance is considered past non-compliance. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 435072