Five Counties Nursing Home

F-F909.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 67 435090 Department of Health & Human Services Printed: 09/04/2025 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 435090 B. Wing 03/12/2025

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

Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638

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 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51472

Residents Affected - Some Based on observation, interview, and policy review, the provider failed to assess side rails on 13 of 13 sampled residents' beds (2, 3, 5, 6, 9, 13, 16, 21, 23, 24, 25, 36, and 142) routinely as a part of a safety and preventative maintenance program to ensure those side rails were in good working order and safe from possible resident entrapment or injury. Findings include:

1. Observation on 3/9/25 at 2:31 p.m. of resident 36 revealed she had two quarter-length side rails in the up position at the head of her bed.

2. Observation on 3/9/25 at 2:32 p.m. of resident 24 revealed she had two quarter-length side rails in the up position at the head of her bed.

3. Observation on 3/9/25 at 2:36 p.m. of resident 9 revealed he had two quarter-length side rails in the up position at the head of his bed.

4. Observation on 3/9/25 at 3:42 p.m. of resident 5 revealed she had two quarter-length side rails in the up position at the head of her bed.

43844

5. Observations on 3/9/25 between 3:48 p.m. and 5:30 p.m. and on 3/10/24 between 8:12 a.m. and 11:00 a. m. of sampled resident rooms revealed 2, 3, 5, 6, 9, 13, 16, 21, 23, 24, 25, 36, and 142 had quarter-length side rails on one or both sides of their beds.

6. Interview on 3/11/25 at 3:09 p.m. with maintenance director F regarding safety and preventative maintenance of side rail on residents' beds revealed:

*The physical therapists initiated the use of side rails for residents.

*He was aware of one bed with side rails attached, the bed in room [ROOM NUMBER].

-That resident was not an identified sampled resident.

-That resident had purchased his own bed, and it had a box spring and metal frame, and on 5/2/24 maintenance director F had installed side rails on that bed.

-He monitored only that residents' bed and the side rails attached to it monthly for safety.

*He thought all other residents' beds with side rails in the up position were for the remote of the electronic bed.

*He was not aware the other residents' beds with side rails attached were being assessed by the nursing staff for use as side rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 67 435090 Department of Health & Human Services Printed: 09/04/2025 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 435090 B. Wing 03/12/2025

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

Five Counties Nursing Home 405 6th Avenue West Lemmon, SD 57638

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 0909 -He had not performed safety and preventative maintenance of side rails for any other residents' beds with side rails to ensure they were appropriately secured and in safe working order to prevent injuries. Level of Harm - Minimal harm or potential for actual harm 7. Review of the provider's Transfer Bar/Bed Rail Maintenance Log revealed:

Residents Affected - Some *The form included areas to be documented in as: date, Room # [number] Monitored, Date Repairs Done, Comments, and Initials.

-The first date on the form was on 5/2/24 with Room # Monitored as #11-2, Date Repairs Done 5-2 installed, Comments included will check quarterly and the Initials of [maintenance director F].

Review of the provider's undated Bed Assist Bar Policy & Procedure revealed:

*Policy:

-Ensure ongoing assessment and maintenance of resident bed assist bar use.

*Procedure:

-4. Initial actions to prevent deaths and injuries from entrapment and/or falls from bed assist bars:

--a. Ensure bed dimensions are appropriate for resident.

--b. Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed.

--c. Check with the manufacturer(s) to make sure the bed assist bar, mattress, and bed frame are compatible.

--d. Install bed assist bars using the manufacturer's instructions and specifications to ensure a proper fit.

-5. Inspect and regularly check the mattress and bed assist bar for areas of possible entrapment.

--a. Regardless of mattress width, length, and/or depth, the bed frame, bed assist bar, and mattress should leave no gap wide enough to entrap a resident's head or body.

--b. Check bed assist bars regularly to make sure they are still installed correctly as bars may shift or loosen of loosen over time.

--c. Follow manufacturer equipment alerts and recalls.

--d. Conduct routine preventative maintenance of beds and bed assist bars to ensure they meet current safety standards and are not in need of repair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 67 435090