Firesteel Healthcare Center

F-F880.

2. Interview and record review on 4/25/25 at 11:19 a.m. with administrator A regarding their quality assurance and performance improvement (QAPI) activities revealed:

*Administrator A reviewed their QAPI data on an Excel spreadsheet with the surveyor.

*Their QAPI committee met at least monthly to review data and quality measures.

-During their meetings, they reviewed the previous month's audits and data.

-For example, their January reports reflected data gathered in December.

*They identified infection control as a performance measure to track monthly.

-Data gathered included hand hygiene and PPE compliance.

-Audits were completed monthly to track performance.

*Their plan of correction (POC) for those areas included continuing to educate staff about the importance of hand hygiene and following PPE guidelines.

*It was identified that their POC did not include actions beyond educating staff, and their compliance percentages continued to fall below their identified benchmarks each month from January to April 2025 (that data would have reflected December 2024 through March 2025).

*They had not tried any other documented methods to increase hand hygiene and PPE compliance to improve their identified infection control concerns.

3. Review of the provider's QAPI report records revealed:

*Their compliance benchmark for both hand hygiene and PPE was set at 95% on one page of their QAPI report, but was set at 100% on a different page.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 0867 *According to their 2025 data, their monthly compliance percentages were as follows:

Level of Harm - Minimal harm or -For hand hygiene: 90% compliance for January, February, March, and April. potential for actual harm -For PPE: 85% in January, February, and March, and 90% in April. Residents Affected - Some *Notes from their January 2025 QAPI meeting included:

-Hand hygiene: Investigation: Hand [Hygiene] was at about 90% this month. At times, it was noted that staff did not use hand sanitizer after coming out of rooms each time. Plan of Correction: ICP [infection control program] continue to educate staff [of] the importance of hand [hygiene] and using hand sanitizer after each room. Use of soap and water after 3 times of hand sanitizer usage.

--There was a section for Outcome, but nothing was noted in that section.

-PPE compliance: Investigation: PPE compliance was at about 85% this month. Staff would go into COVID rooms with surgical masks on and not N95 [a specialized face mask]. Gowns not being worn at all times

during cares in EBP [enhanced barrier precautions] rooms. Plan of Correction: ICP continue to educate staff [of] the importance of the signs on the doors and wearing the correct PPE. List of COVID positive residents were placed at the [nurse's] station to make staff more aware of which residents required the special quarantine precautions. Outcome: Once staff were reminded on the importance of correct PPE usage, this improved.

*Notes from their February 2025 QAPI meeting included:

-The hand hygiene notes were identical to January's notes.

-PPE compliance: Investigation: PPE compliance was at about 85% this month. Gowns not being worn at all times during cares in EBP rooms. Plan of Correction: ICP continue to educate staff [of] the importance of the signs on the doors and wearing the correct PPE.

--There was a section for Outcome, but nothing was noted in that section.

*Notes from their March 2025 QAPI meeting included:

-The hand hygiene notes were identical to January's and February's notes.

-The PPE compliance notes were identical to February's notes.

-PPE Plan of Correction: ICP continue to educate staff [of] the importance of the signs on the doors and wearing the correct PPE. Outcome: EBP rooms audited and precautions taken down if did not meet criteria to help with importance of PPE.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46453

Residents Affected - Some Based on South Dakota Department of Health (SD DOH) complaint intake review, observation, interview,

record review, and policy review, the provider failed to ensure proper infection control practices were followed regarding:

*Hand hygiene practices by staff members BB, GG, and HH during two of two dining observations in two of three dining rooms.

*Hand hygiene and personal protective equipment (PPE) use by three of three staff observed (L, M, and BB)

during personal cares for one of one sampled resident (41), personal cares for one of one sampled resident (33) on contact precautions (which indicated staff should have worn gowns and gloves), and assisting with resident transportation for two of two sampled residents (33 and 85).

Failure to follow infection control practices potentially contributed to a norovirus [a highly contagious virus that causes nausea, vomiting, and diarrhea] outbreak in April 2025 which included three residents (18, 40, and 76) with confirmed norovirus infections and at least forty-two additional residents (1, 2, 3, 4, 12, 13, 14, 16, 22, 23, 24, 25, 29, 30, 31, 33, 34, 35, 36, 41, 42, 43, 45, 53, 58, 60, 64, 65, 67, 68, 69, 77, 78, 79, 80, 85, 93, 99, 100, 107, 258, and 259) with identified gastrointestinal (GI) symptoms.

Findings include:

1. Review of the 4/16/25 SD DOH complaint intake form revealed:

*An anonymous email reported a concern that the provider had a severe outbreak of norovirus.

*The anonymous reporter was concerned the provider was not monitoring hand washing, sanitation, [and] dishwashing.

*The writer was fearful for their family member that resided at the facility.

2. Review of a separate SD DOH complaint intake received on 4/16/25 revealed:

*The complainant reported that resident 107 was recently hospitalized and had to be admitted to the intensive care unit (ICU).

Review of resident 107's electronic medical record (EMR) revealed:

*On 4/9/25, she experienced vomiting, diarrhea, weakness, and confusion. She was unable to speak coherently.

*On 4/9/25 around 4:45 p.m., she was sent to the local emergency room for evaluation.

-She was then admitted to the ICU for a diagnosis of pneumonia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 continued to experience diarrhea throughout her hospitalization .

Level of Harm - Actual harm *She returned to the facility on [DATE REDACTED].

Residents Affected - Some 3. Observation on 4/22/25 at 3:51 p.m. of certified nurse aide (CNA) M and CNA/certified medication aide (CMA) BB performing personal cares for resident 41 revealed:

*Both CNAs performed proper hand hygiene before putting on clean pairs of gloves.

*Resident 41 had been incontinent of bowel, and they cleaned her up and removed the soiled brief.

*Without removing her gloves or performing hand hygiene, CNA/CMA BB walked over to resident 41's wardrobe and touched the door handles, rummaged around in the wardrobe, and grabbed a clean brief.

*She continued to assist resident 41 with putting on the clean brief with those same soiled gloves on.

*Both CNAs kept on their same pair of soiled gloves throughout the process of changing resident 41's brief, getting her cleaned up, and redressing resident 41.

*Both CNAs then removed their gloves and did not perform hand hygiene.

*With their unclean hands, they touched:

-The resident's sling used for the full body lift.

-The full body lift.

-The resident's positioning pillow.

-The resident's wheelchair.

-The door handle to exit the room.

-CNA M also touched the resident's water cup, held the straw between her right index and middle fingers, and helped resident 41 take a drink of water.

*CNA/CMA BB wrapped up the trash and walked away with it down the hallway.

-After she came back, she brought the full body lift out into the hallway and cleaned it.

*Neither of them were observed to have performed hand hygiene after assisting the resident.

4. Interview on 4/22/25 at 4:10 p.m. with both CNA M and BB about the above observation revealed:

*Neither of them realized they had missed several opportunities for hand hygiene and changing their gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *CNA M questioned how soon she should have performed hand hygiene after removing her gloves as she explained she came out here [the hallway] to do that, is that not soon enough? Level of Harm - Actual harm -The surveyor explained that she touched the resident's water cup and drinking straw after removing her Residents Affected - Some gloves and had not yet performed hand hygiene after assisting the resident with personal care. Her contaminated hands potentially increased the risk of spreading infection.

-She agreed she had done that and promptly walked away from the conversation.

5. Observation on 4/22/25 at 4:41 p.m. of CNAs L and M in resident 33's shared room revealed:

*There was a sign on the door for Contact Precautions which explained what PPE each person entering the room was required to wear.

-PPE was available and hanging on the door.

*CNA M came out of resident 33's side of the room with no evidence that she had worn PPE while interacting with the resident.

*CNA L came out of resident 33's side of the room with the full body lift and parked it in the hallway. She was not wearing any PPE.

-She did not clean the lift.

*She did not put on any PPE and then went back into resident 33's side of the room.

*She came back out of the resident's room, wearing one glove on her left hand and was holding a small bag of trash. There did not appear to be any PPE in the small trash bag.

*She was holding the bag of trash while she was pushing resident 33 in her wheelchair down the hallway.

-She was touching the left wheelchair handle with the same hand that she was holding the trash with.

*She wheeled the resident all the way down the 400-hallway and turned towards the rehab dining room.

*By 4:56 p.m., no staff had come back to clean the lift.

6. Interview on 4/22/25 at 4:58 p.m. with licensed practical nurse (LPN) N revealed:

*She confirmed that resident 33 had an order for contact precautions, but she was not sure why the resident was on contact precautions.

-She wondered if it was from the gastrointestinal (GI) bug that went through the building for the past several weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 -When reviewing resident 33's record, she confirmed that the resident had diarrhea and vomiting the previous week. Level of Harm - Actual harm *She explained that contact precautions were implemented for residents known or suspected to be infected Residents Affected - Some with infectious agents transmitted [from] person-to-person.

*For contact precautions, she expected staff to wear at least a gown and gloves when providing care to the resident, even for transferring.

-If staff were physically touching the resident, she expected staff to wear PPE for infection control purposes.

*She indicated that the contact precautions for resident 33 were no longer necessary since her GI symptoms had subsided several days ago.

-She discontinued that order for contact precautions in resident 33's electronic medical record (EMR).

*She did not know exactly why the contact precautions sign and the PPE were still on resident 33's door and guessed that someone may have forgotten to discontinue the precautions after she was symptom-free.

*She expected staff to have followed the contact precautions signage and use the proper PPE or contact a nurse if there were any questions.

7. Interview on 4/22/25 at 5:05 p.m. with CNA L revealed:

*She could not remember how long she had been working at that facility.

*When asked if she knew which resident in the shared room from the above observation was on contact precautions, she indicated that she did not know how to tell which resident in that room was on contact precautions.

*She confirmed that neither she nor CNA M wore gowns while interacting with resident 33, they only wore gloves.

*When asked if she knew what contact precautions meant, she said that they were supposed to wear gowns, gloves, and sometimes a face shield when interacting with the resident.

*She said she also caught the GI bug that was going around the facility recently.

*When asked why she did not follow the contact precautions as posted on the door and in the resident's orders, she said, I don't know, that's what I was trained to do, to just follow the other CNA.

*When asked how often she was to clean the lift, she indicated that it was supposed to have been cleaned

after each resident's use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 still did not clean the lift after being informed that she had not cleaned the lift after taking it out of the resident's room. Level of Harm - Actual harm 8. Observation on 4/22/25 at 5:11 p.m. revealed LPN N was removing the contact precautions sign and PPE Residents Affected - Some off resident 33's door.

9. Observation on 4/22/25 from 5:34 p.m. to 5:40 p.m. in the rehab dining room revealed:

*CNA/CMA BB was sitting between two residents (41 and 56) to help them eat supper.

*With her bare hands, she touched her hair braids to push them back behind her shoulders.

*Without performing hand hygiene, she continued to help the two residents eat their meals.

-She was taking straws out of their wrappers and placing the straws into the residents' beverages, touching

the resident's silverware handles, squeezing condiments out of packets, and wiping the residents' mouths with their napkins.

50915

10. Observation on 4/22/25 at 5:49 p.m. of the evening meal on the memory care unit (MCU) revealed:

*Residents were not assisted with cleaning their hands before their meal.

*CNA HH did not sanitize her hands before she passed the residents' meal trays.

*She was observed coughing into her hand, she did not sanitize her hands after coughing, then she delivered the resident's meal tray.

*There was a potentially contaminated rehabilitation cone device on the table.

-A resident grabbed the cone and appeared to have been trying to take a drink from the cone as he picked it up and brought it to his mouth.

-CNA HH noticed this and gently removed the potentially contaminated cone from his hands. She continued serving meal trays without performing hand hygiene.

*She served nine residents their meal trays and did not sanitize her hands.

11. Observation on 4/23/25 at 9:29 a.m. of the morning meal service on MCU revealed:

*Some residents were sitting at the table prior to meal service.

*CNA GG did not perform hand hygiene before assisting residents with eating.

*CNA GG was observed assisting a resident to eat after the resident had coughed.

-The resident was not offered hand sanitizer or a hand wipe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *CNA GG then moved to another table without sanitizing her hands and assisted a different resident with eating. Level of Harm - Actual harm 12. Observation on 4/23/25 at 10:09 a.m. near the 400-hallway nurse's station revealed: Residents Affected - Some *CNA M had a glove on her right hand and was holding a bag of trash.

*At the same time, she was touching resident 85's wheelchair handle as she pushed him down the hallway.

13. Interview on 4/24/25 at 8:43 a.m. with resident 33 revealed:

*She confirmed:

-She had the GI bug earlier that month.

-Staff did not put on gowns when they helped her with personal cares.

*She was no longer experiencing GI symptoms like vomiting or diarrhea.

Review of resident 33's electronic medical record revealed:

*Her quarterly Minimum Data Set (MDS) assessment completed on 4/4/25 revealed a Brief Interview for Mental Status assessment score of 14, which indicated she was cognitively intact.

*A nursing progress note from 4/8/25 that read, Contact precautions and isolation to room implemented per protocol for GI illness.

*She experienced diarrhea on 4/8/25, 4/9/25, 4/10/25, and 4/11/25.

*A physician's order started on 4/8/25 for Contact precautions as recommended for residents known or suspected to be infected with infectious agents transmitted person to person via the direct/indirect contact route (e.g. VRE [Vancomycin-resistant Enterococcus], Clostridium Difficile, MRSA [Methicillin-resistant Staphylococcus aureus] etc.).

14. Interview on 4/24/25 at 11:32 a.m. with LPN FF regarding resident and staff hand hygiene during meal service revealed:

*There was usually hand sanitizer on the tables for residents to use before meals.

*Residents were given a hand wipe to clean their hands with their meals.

*It was her expectation that staff assisting residents with eating would sanitize their hands before assisting a resident, and before assisting the next resident.

15. Interview on 4/24/25 at 1:50 p.m. with CMA II revealed:

*She was aware of a GI outbreak in the facility the past couple weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 reported the outbreak was facility-wide and included many residents and staff members.

Level of Harm - Actual harm *She reported if she were assisting residents to eat, she would sanitize her hands before assisting residents, then after assisting them before she assisted another resident. Residents Affected - Some 16. Interview on 4/25/25 at 10:15 a.m. with resident care manager registered nurse (RN) G revealed:

*She was a the provider's infection preventionist.

*There was an outbreak of norovirus in the facility during April 2025.

*They tested three residents, each from different wings of the facility, all were positive for norovirus.

*After that initial testing, all residents with GI symptoms (nausea, vomiting, diarrhea) were assumed to have norovirus and were tracked for infection control purposes.

*Residents with symptoms were placed on contact precautions to prevent further spread of the virus.

*Residents remained on contact precautions for 24 hours after symptoms stopped.

17. Interview on 4/25/25 at 10:51 a.m. with director of nursing services (DNS) B and division director of clinical services (DDCO) C revealed:

*DNS B recently started her position at the facility on 4/7/25.

*Since the resident GI symptoms started on 4/8/25, she was fully aware of the GI outbreak.

-In her time at that facility, she noted concerns in infection control such as hand hygiene.

*On 4/8/25, residents who were experiencing diarrhea and vomiting were placed on contact precautions.

*The staff collected and sent stool cultures to the laboratory for testing from three residents that had GI symptoms (residents 18, 40, and 76). Those residents resided in different areas of the facility. On 4/12/25, those stool culture results came back positive for norovirus.

*Both DNS B and DDCO C appeared disappointed when they were informed about the above observations.

-They expected staff to have followed the provider's policies on hand hygiene, glove use, and contact precautions.

*A total of 45 residents were affected.

-The census at the time of the survey was 104.

18. Review of the provider's Line listings for infections by resident tracking sheet revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *Between 4/6/25 and 4/14/25, a total of 45 residents (1, 2, 3, 4, 12, 13, 14, 16, 18, 22, 23, 24, 25, 29, 30, 31, 33, 34, 35, 36, 40, 41, 42, 43, 45, 53, 58, 60, 64, 65, 67, 68, 69, 76, 77, 78, 79, 80, 85, 93, 99, 100, 107, 258, Level of Harm - Actual harm and 259) had been identified to have GI symptoms.

Residents Affected - Some 19. Review of the provider's March 2018 handwashing/hand hygiene policy revealed:

*Policy statement: This Center considers hand hygiene the primary means to prevent the spread of infections.

*Procedure:

-1. Personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.

-2. Personnel follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

20. Review of the provider's May 2015 Initiating Transmission-Based Precautions policy revealed:

*Policy Statement: Transmission-Based Precautions are initiated when there is reason to believe that a resident has a communicable infectious disease.

-Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions.

*Procedure:

-1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor notified the Infection Preventionist and the resident's Attending Physician for appropriate Transmission-Based Precautions.

- .4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occur after pertinent criteria for discontinuation are met.

-5. When Transmission-Based Precautions are implemented, the Infection Preventionist or designee:

--a. Validates protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need;

--b. Posts the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. This Center's process for notification is signage .

-6. In an emergency, the Infection Preventionist, [Executive Director], and/or Medical Director have the administrative authority, accountability, and responsibility to:

--a. Institute actions necessary to control or prevent infections within the Center;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 --b. Notify the health department of reportable diseases, as appropriate;

Level of Harm - Actual harm --c. Initiate isolation precautions;

Residents Affected - Some --d. Obtain laboratory specimens;

--e. Restrict or ban admissions;

--f. Restrict or ban visitations;

--g. Implement other measures as necessary to prevent and control infections within the Center.

21. Review of the provider's March 2025 Transmission-Based Precautions (Isolation) policy revealed:

*Policy Statement: Transmission-Based Precautions (previously referred to as isolation precautions) are implemented for residents known to be, or suspected of being, infected with infectious agents.

*Procedure:

-1. Use Transmission-Based Precautions in addition to Standard Precautions.

-2. The four types of Transmission-Based Precautions may be used alone, or in combination for diseases that have multiple routes of transmission. Determination of use is based on how the infectious agent is transmitted.

--Contact precautions.

--Droplet precautions.

--Airborne precautions.

--Enhanced barrier precautions.

-3. The need to implement Transmission-Based Precautions is determined by the [facility's] Infection Preventionist (IP), Director of Nursing and/or consultation with the local health department. Precautions are based on CDC [Centers for Disease Control and Prevention] guidelines. Precautions are the least restrictive possible for the resident.

-4. The facility documents in the resident's medical record the rationale for the type of transmission-based precautions selected as well as the length of time the precautions is maintained.

-5. Communication of Transmission-Based Precautions is accomplished with the pertinent signage and verbal reports to personnel and visitors.

-6. Residents on TBP [Transmission-Based Precautions], apart from EBP [Enhanced Barrier Precautions], should remain in their room for the duration of precautions, except for medically necessary care or resident choice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 -7. Indirect transmission of infectious agents can occur through contact with resident care equipment. Whenever possible, personal care items such as thermometers, stethoscopes, blood pressure cuffs and gait Level of Harm - Actual harm belts will be dedicated for use by the resident needing contact, droplet, or airborne precautions. All reusable items, including glucometers and other point-of-care devices are cleaned using appropriate disinfectant after Residents Affected - Some using the devices with individual residents.

*Contact Isolation Precautions:

-Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the resident, through contact with the resident's environment, or by using contaminated gloves or equipment.

-Personnel having contact with the infected resident should wear gloves and a gown.

-Prior to leaving the resident's room, gown and gloves are removed and hand hygiene performed.

-Options for residents on contact precautions may include a private room, cohorting with another infected or colonized resident or sharing a room with a resident with limited risk factors (no immunosuppression, IVs, indwelling catheters or open skin lesions).

-Residents with wound drainage, fecal incontinence, or diarrhea, that cannot be contained, should be placed

on contact precautions until a specific organism for the origin of the medical issue is identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43021

Residents Affected - Few Based on interview, observation, record review, and policy review, the provider failed to ensure effective pest control for flying ants for one of twenty-six sampled residents (91) who complained of flying ants in his room and ant bites on his back.

Findings include:

1. Interview and observation on 4/23/25 at 10:56 a.m. with resident 91 in his room revealed he stated:

*He was having a problem with flying ants in his room.

*The problem was daily and he had killed 30 to 40 of the flying ants every day.

*The maintenance guy thinks they are coming in from behind [the] heater that was located on the wall below

the window in his room.

*Every morning his bedside table was covered with them and four to five of the flying ants were in his bed.

-He had bites all over his back from the flying ants.

-Resident 91 lifted the back of his shirt and showed his back which appeared to have several small red marks on his mid back.

*Resident 91 stated he had been having problems with the flying ants for several weeks.

-He stated I can feel them [flying ants] when they bite, they grab your attention.

*He stated that yesterday (4/22/25), staff had asked him if he would like to move to another room, but he liked his current room.

-He was asked to vacate his room for a couple of hours, and said that three staff members had been in his room.

-When he woke up this morning (4/23/25), there were around 40 flying ants on his nightstand.

*There were three dead flying ants on his nightstand which he stated he had killed with a tissue.

*Maintenance assistant X was outside the resident's window with a spray bottle which he used to spray at

the area below the window.

*A round container of ant bait was on the floor by the window next to the heater on the wall.

*A liquid ant bait was on the floor by the wall at the head of resident 91's bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 0925 2. Observation on 4/23/25 at 11:22 a.m. revealed resident 91 walked into the hallway with his walker and stated he had a bug on his window screen. Upon entering his room, an active flying ant was observed on the Level of Harm - Actual harm window screen in his room.

Residents Affected - Few 3. Observation and interview on the morning of 4/24/25 with resident 91 and staff in his room revealed:

*At 7:55 a.m. the resident was in his room eating his breakfast and he:

-Stated that social services director (SSD) E had brought in his breakfast that morning.

-Pointed to seven dead flying ants on his nightstand, and stated he had used a paper napkin to kill them.

-Stated five flying ants were in his bed that morning.

*At 7:58 a.m. maintenance supervisor (MS) W and SSD E entered his room and asked him about moving to another room.

-SSD E offered to move him to another room so they could deal more effectively with the flying ant problem.

-SSD E escorted the resident out of the room to show him the other room.

-MS W stated they had been working on the flying ant problem for a few weeks:

--They had offered to move the resident multiple times.

--He had a bug control contractor in to service resident 91's room and he would provide those invoices.

*At 8:06 a.m. SSD E stated the resident had agreed to move to the other room that day.

4. Interview on 4/24/25 at 8:15 a.m. with restorative aide Y regarding the problem with flying ants revealed

she had seen flying ants in a room on the 500 hallway and a room on the 400 hallway:

*In the 400 hallway's room, she had seen flying ants about a week ago, but not since then in that room.

*She felt the flying ant problem in the 400 hallway's room had been taken care of.

5. Interview on 4/24/25 at 9:30 a.m. with administrator A regarding the flying ants revealed he had:

*A pest control company come into the facility to service the affected room, and after several treatments, the pest control company had told him they could not do anything more regarding the flying ants.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 0925 *Staff deep cleaned resident 91's room on Tuesday, 4/22/25, as they felt the snacks resident 91 kept in his room had attracted the flying ants. Level of Harm - Actual harm *They had also set out bait traps to help with the flying ants. Residents Affected - Few 6. Interview on 4/24/25 at 4:33 p.m. with resident 91 in his new room revealed:

*He stated he was moved into the room by 10:30 a.m. that morning.

*The staff had moved his bed and recliner from his other room.

*He had not seen any flying ants in his current room yet.

7. Observation on the afternoon of 4/24/25 of resident 91's previous room revealed:

*At 4:39 p.m. the room was empty except for one dining room chair and an overbed table.

-Two live and active flying ants were noted on the window screen in the room.

-There was a sticky strip hanging from the ceiling by the window.

-There were three (Product name) liquid ant baits noted on the floor by the base board.

-An ant bait was by the heater unit on the floor below the window.

*At 4:46 p.m. certified medication assistant/certified nursing assistant (CMA/CNA) BB entered the room and confirmed there were two flying ants on the window screen.

8. Interview on 4/25/25 at 11:00 a.m. with resident 91 in his new room revealed he stated:

*He hasn't seen a bug yet and was in a good mood.

*Had a good night's sleep and had slept for ten hours.

9. Interview on 4/25/25 at 11:03 a.m. with SSD E revealed she had become aware of the issue with the flying ants yesterday, 4/24/25. When she had delivered resident 91's breakfast tray into his room he had stated he was having a problem with the flying ants in his room.

10. Interview on 4/25/25 at 11:21 a.m. with MS W revealed:

*He had reviewed his records. He had become aware of the flying ants in resident 91's room on 4/11/25 when a work order was entered into their electronic maintenance software system called Technology-Enabled Life Safety (TELS).

*In response, they had done the following in resident 91's room:

-Deep cleaned resident 91's room as they felt the snacks resident 91 kept in his room had attracted the flying ants.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 0925 -Placed containers of ant bait on the floor in resident 91's room.

Level of Harm - Actual harm -Sprayed ant killer on the outside of the facility by resident 91's room.

Residents Affected - Few *He had requested the pest control company provide treatment for the flying ants.

*He confirmed the flying ants had continued to be a problem as of 4/23/25, when resident 91 had reported

the problem to the surveyor.

11. Interview on 4/25/25 at 12:15 p.m. with administrator A revealed he had become aware of the flying ants problem at about the same time as MS W had on 4/11/25.

12. Review of the provider's invoices from the contracted pest control company revealed invoices for monthly contract services detailing:

*Target: Spiders, Ants, Roaches.

*Location: Interior Baseboards, Kitchen.

*On the following dates:

-1/8/25.

-2/3/25.

-3/5/25.

-4/1/25.

*There was no documentation of the pest-control company having an additional visit or involvement after 4/1/25.

Review of an e-mail communication from the provider's contracted pest control company revealed a message on 4/24/25 at 8:34 a.m. stated We were there for monthly scheduled service on March 4th and April 1. We did an extra call on March 21st to spray for ants .

Interview on 4/24/25 at 4:55 p.m. with administrator A revealed the provider had no invoice from the contracted pest control company for 3/21/25, but he verified they had provided service at the facility on that date.

Review of the requested provider's TELS Work Orders regarding the flying ants revealed:

*Work Order #3833 created on 4/11/25 at 3:43 p.m. by licensed practical nurse (LPN) Z regarding resident 91's room indicated:

-Comments: Resident states that he has flying ants coming in his room by his window.

-Updated Status: 4/14/25 at 10:48 a.m. Set to Completed by maintenance assistant X.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 38 435109 Department of Health & Human Services Printed: 08/28/2025 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 435109 B. Wing 04/25/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 0925 --Notes: Housekeeping deep cleaned area, Maintenance checked area and posted Ant traps,

Level of Harm - Actual harm resident offered to move and declined.

Residents Affected - Few *Work Order #3847 created on 4/17/25 at 7:42 a.m. by CMA AA regarding resident 91's room indicated:

-Notes: Resident stated he killed about 15-20 bugs located in his bed and inside of his dresser.

Resident states that the strips in the windows do not serve a purpose.

-Updated Status: 4/18/25 at 2:54 p.m. Set to Completed by maintenance assistant X.

-Notes: [Maintenance assistant X] 04/18 [4/18/25] Traps have been placed, sprayed for bugs, housekeeping has been notified to deep clean [that room] regularly.

*Work Order #3858 created 4/22/25 at 6:55 a.m. by LPN N regarding room [ROOM NUMBER].

-Updated Status: 4/22/25 at 7:36 a.m. Set to Completed by MS W.

-Notes: House keeping deep cleaned residents [resident's] room, found many food particles all over [the] ground.

Maintenance silicone sealed flooring and pest control had recently been out to spray. Also Ant traps placed.

Review of the provider's May 2015 Pest Control policy revealed:

*Purpose: To provide an environment free of pests.

*Procedure: The Center has a pest contract that provides frequent treatment of the environment for pests. It allows for additional visits when a problem is detected.

-Monitoring of the environment is done by the Center's staff. Pest control problems are reported promptly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 38 435109