St William's Care Center

F-F600, finding 12.

3. Interview on 7/23/24 at 4:49 p.m. with administrator A regarding the alleged incidents revealed:

*One of the other certified nursing assistants (CNAs) came to her The other day and told her [CNA J] is a little cross with the residents.

*After nurse aide (NA) M reported the incidents to her the previous week, she texted director of nursing (DON) B.

-DON B had worked a nurse shift that evening.

-She told DON B to tell [CNA J] she has to watch her interactions.

*She confirmed she knew about the incident between CNA J and resident 3.

*She initially denied knowledge of the incident between CNA J and resident 4.

-[CNA J] has had trouble with [resident 4] but I'm not aware of that particular incident.

-However, when detailing the incident further, especially when resident 4 expressed He's a hateful person, administrator A did remember that incident.

*She kept a daily log of conversations she has had throughout the day.

-She could not remember exactly when NA M reported those incidents.

*She confirmed she had not reported either allegation to the required entities, and she had not investigated either incident further.

4. Interview on 7/24/24 at 11:03 a.m. with administrator A about the alleged incidents revealed:

*She confirmed she was not informing the other department heads, like registered nurse (RN) C the staff development coordinator, about certain incidents in an attempt to maintain confidentiality.

-If an incident involved a CNA, she would have only let DON B know about the situation.

-She had not considered bringing the staff development coordinator into the conversation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 435122 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 435122 B. Wing 07/24/2024

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

St William's Care Center 103 N Viola St Milbank, SD 57252

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 0610 *Her investigation process included to:

Level of Harm - Minimal harm or -Review schedules. potential for actual harm -Interview those staff who were on shift and were involved. Residents Affected - Few -Speak to each person individually.

-Try to maintain confidentiality.

*She felt the incidents involving CNA J and residents 3 and 4 were probably true because the staff member that reported those incidents was reliable.

*She indicated that she started an investigation into the allegation involving resident 4 and CNA J and had submitted an initial report to the South Dakota Department of Health.

5. Review of the provider's 7/19/24 updated Abuse, Neglect and Misappropriation of Resident Property policy revealed:

*Policy: Residents at [facility] will be treated with dignity and respect. No resident of this facility will be mistreated, abused or neglected.

*This abuse plan has been implemented to protect our residents. The responsibility for carrying out this plan will ultimately lie with the Administrator and the staff employed by [facility] but involves every person in contact with residents.

*Process:

-Identification: Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; staff will determine the direction of an investigation.

-Investigation: Alleged violations will be investigated and will be reported to proper authorities by the administrator, director of nursing or their representative

-Protection: Residents will be protected from harm during an investigation. Staff may need to be reassigned to other areas or suspended until the investigation is completed.

-Reporting/Response: The facility must report all alleged violations involving mistreatment, neglect, or abuse, including injuries on unknown source and misappropriation of resident property immediately to the administrator or their representative.

-The SD Department of Health must be notified immediately but not later than 2 hours if serious bodily injury occurred, within 24 hours of incident if no serious bodily injury.

-Notify law enforcement only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 435122 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 435122 B. Wing 07/24/2024

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

St William's Care Center 103 N Viola St Milbank, SD 57252

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 0610 -The results of the investigation must be reported to the SD Department of Health, [the local police department] (if required to notify), and the SD Department of Human Services (if required to notify) within 5 Level of Harm - Minimal harm or working days of the incident, and if the alleged violation is verified appropriate corrective action must be potential for actual harm taken.

Residents Affected - Few -The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further abuse while the investigation is in progress. The facility must analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences.

-If the alleged violation is verified, appropriate corrective action, which may include termination of employment, will be taken to prevent further occurrences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 435122 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 435122 B. Wing 07/24/2024

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

St William's Care Center 103 N Viola St Milbank, SD 57252

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 50015 Residents Affected - Few Based on interview, observation, and policy review, the provider failed to follow their policy to ensure a controlled medication (one easily diverted by staff) was securely stored for one of one (1) resident. Findings include:

1. Interview on 7/23/24 at 12:46 p.m. and again at 2:09 p.m. with medication aide (MA) E revealed:

*Resident 1 received Tramadol (a controlled pain medication) 50 milligrams (mg) tablet twice daily.

*The Tramadol 50 mg tablets were kept in the same location as other scheduled dose medications and were not double-locked.

*She was aware Tramadol was a controlled substance medication.

*Controlled medications that were for PRN (as needed) use were stored in the double-locked drawer are were counted at shift change.

*Scheduled controlled medications were counted before and after they were administered.

*She confirmed they do not count the scheduled controlled medications at shift change.

2. Interview on 7/24/24 at 9:47 a.m. with licensed practical nurse (LPN) D revealed:

*PRN Tramadol was stored in the double-lock box in the medication cart.

*Only the scheduled controlled medications like Tramadol and Clonazepam (a sedative) are kept with other scheduled medications.

3. Observation on 7/24/24 at 10:32 a.m. with MA E revealed:

*She removed a current Tramadol dosing card for resident 1, from the top drawer of the medication cart.

*That drawer was only secured by one lock.

4. Interview on 7/24/24 at 11:58 a.m. with director of nursing (DON) B revealed:

*Scheduled Tramadol is kept with other scheduled medications in the medication cart.

*PRN narcotic medications are in the double-lock drawer.

*This is the provider's normal practice for controlled medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 435122 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 435122 B. Wing 07/24/2024

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

St William's Care Center 103 N Viola St Milbank, SD 57252

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 0761 *The double-lock drawer is not big enough for all the controlled medications.

Level of Harm - Minimal harm or *She agreed that having the scheduled Tramadol doses with other scheduled medications did not follow their potential for actual harm current Controlled Substance-Narcotic Medication Management Policy.

Residents Affected - Few 5. Review of the provider's 7/14/23 Controlled Substance-Narcotic Medication Management policy revealed:

*All scheduled II-V medications are maintained in separately locked, permanently affixed compartment of the medication cart.

*All controlled substances, including ER narcotic kit and medications in the refrigerator, must be counted at each shift change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 435122

F-F602 occurred on 7/13/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 7/22/24, the non-compliance is considered past non-compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 435122 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 435122 B. Wing 07/24/2024

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

St William's Care Center 103 N Viola St Milbank, SD 57252

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 46453

Residents Affected - Few Based on interview, record review, and policy review, the provider failed to report allegations of abuse to the required entities in the required timeframe for two of two incidents of alleged abuse involving two of three sampled residents (3 and 4). Findings include:

1. Interview on 7/23/24 at 1:42 p.m. with certified nursing assistant (CNA) L about reporting of alleged violations revealed:

*She was able to verbalize the correct reporting procedures.

*She had not reported any incidents recently.

*There were two incidents that she knew a different CNA reported last week.

-Both incidents involved CNA (J).

-One incident involved resident 3, and the other incident involved resident 4.

-She was not present for either incident but heard about them from a coworker.

2. Refer to