Avantara Arrowhead

F-F600 was determined on 3/22/25 and the provider's implemented 3/25/25 corrective actions for the deficient practice confirmed on 3/26/25, 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 6 435051 Department of Health & Human Services Printed: 09/03/2025 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 435051 B. Wing 03/26/2025

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

Avantara Arrowhead 2500 Arrowhead Dr Rapid City, SD 57702

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47780 potential for actual harm Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and Residents Affected - Few policy review, the provider failed to ensure one of one sampled severely cognitively impaired resident (3) who developed a skin rash had:

*Been provided adequate scheduled bathing.

*Physician's orders for prompt treatment of the resident's skin rash.

Findings include:

1. Review of the 3/19/25 SD DOH complaint intake form regarding resident 3 revealed:

*The complainant would like to remain anonymous.

*They had concerns regarding the care resident 3 was receiving at the facility.

-They stated resident 3 was not getting bathed as scheduled and staff had not been putting lotion on the resident's dry skin.

Review of resident 3's electronic medical record (EMR) revealed:

*He was admitted on [DATE REDACTED], and his diagnoses included sepsis, urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD), depression, dementia, and diabetes.

*His Brief Interview for Mental Status (BIMS) assessment score was 2, which indicated he was severely cognitively impaired.

*A progress note on 1/13/25 at 6:01 a.m., Resident has red scabby rash on LUE and has a 1x1 [one by one] cm [centimeter] scab on [his] face. Resident was picking at [a] scab and reopened it. Scant bleeding noted. No signs of infection, no other open areas noted. Area cleansed with soap and water. Resident tolerated well, no complaints of pain or discomfort to [the] area. Provider notified via fax. DON [director of nursing] notified via fax. Will pass on to day shift nurse to notify POA [power of attorney].

*A skin assessment on 1/20/25 at 4:52 a.m., Resident has numerous scabbing BUE [bilateral upper extremities/both arms], from [his] shoulders down to [his] hands, some or possibly all of which is due to resident scratching [those area]. Bilateral [both] hips have scratch marks, and [his] LLE [lower left extremity/legs] on upper thigh has a few abrasions. Skin protectant applied to all areas.

*A skin assessment on 1/27/25 at 3:56 a.m., Resident has scabs on upper arms and chest and back due to scratching and picking. No infections noted, open areas.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 435051 Department of Health & Human Services Printed: 09/03/2025 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 435051 B. Wing 03/26/2025

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

Avantara Arrowhead 2500 Arrowhead Dr Rapid City, SD 57702

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 0684 *A progress note on 1/29/25 at 00:00, [midnight] [Resident 3] is a [resident's age] year old male who is seen today at the request of the nursing staff for A&D ointment. He has redness and discomfort in [his] groin area Level of Harm - Minimal harm or and skin folds. Verbal order was given on day of appt [appointment] for A&D ointment [to be] applied prn [as potential for actual harm needed] to reddened, irritated skin prn.

Residents Affected - Few *A skin assessment on 2/2/25 at 7:42 p.m. small, dry, faint red/brown scabs on [his] upper shoulders. bilateral [both] feet: dry and scant flaking noted. redness noted to bottoms of feet and interior right foot red by great toe. groin: no redness noted. abdominal fold: faint blue bruising noted to abdominal area from insulin injections.

*He was discharged to an assisted living center (ALC) on 2/3/25.

Review of resident 3's bath scheduled revealed:

*In December 2024, he received no baths from his admission on 12/13/25 through the end of the month.

*In January 2025, he received four baths.

-There was a two-week period between those four baths which he did not receive a bath.

*In February 2025, he received one bath before he was discharged on [DATE REDACTED].

Interview on 3/26/25 at 9:37 a.m. with certified nursing assistant (CNA)/bath aide E revealed:

*She was unsure why resident 3 did not receive a bath in December 2024.

*She stated that when a resident admitted to the facility, the bath aides would write the resident's name on

the bottom of the bath sheet, she had thought they forgot to add resident 3 to the bath sheet.

*She was unsure why he did not receive a bath for two weeks in January 2025.

*In January 2025, she remembered she had bathed him two times.

-She stated she had noticed the scabs from his scratching had worsened from the first time she bathed him to the last time she bathed him in January 2025.

Interview on 3/26/25 at 9:54 a.m. with agency CNA F revealed:

*She was assigned to care for resident 3's when he resided in the facility.

*She stated she had noticed the scabs on his skin from his scratching had worsened from the first time she had assisted him with morning ADLs [activities of daily living] to one of the last times she assisted him prior to his discharge.

Interview on 3/26/25 at 10:10 a.m. with licensed practical nurse (LPN) unit manager G revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 435051 Department of Health & Human Services Printed: 09/03/2025 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 435051 B. Wing 03/26/2025

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

Avantara Arrowhead 2500 Arrowhead Dr Rapid City, SD 57702

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 0684 *She stated a registered nurse (RN) resident 3 had a rash on 1/16/25.

Level of Harm - Minimal harm or *On 1/22/25, the RN asked the physician in HUCU (electronic communication system) for an anti-itch cream potential for actual harm for resident 3.

Residents Affected - Few -She stated the physician did not respond to the order request for the anti-itch cream.

*On 1/27/25, LPN/unit manager G requested an order for a topical ointment for resident 3 in HUCU.

*She stated that on 1/27/25, the physician's assistant (PA) had given a verbal order for the topical ointment for the resident's skin.

-The topical ointment was started on January 28, 2025.

-The TAR (treatment administration record) has shown it was documented in January 2025 and February 2025 that he was receiving those topical ointment treatments.

*She had been responsible for the residents' bath schedule since January 2025.

*She was unsure why resident 3 did not receive a bath for two weeks in January 2025.

*She stated that when a resident would refuse bathing, bath aides were to document the refusal in their charting.

Interview on 3/26/25 at 11:35 a.m. with administrator A revealed:

*She knew staff was had tried to get the topical ointment for resident 3.

*She was aware the bath schedule was an issue for getting resident bathed timely.

-They have discussed the bathing schedule in QAPI and have opened a PIP (performance improvement project) in January 2025.

Review of the provider's revised 9/11/24 Skin and Pressure Injury Prevention Program policy revealed:

General Guidelines

*5. The facility should have a system/procedure to ensure assessments are timely and accurately and changes in condition are recognized, evaluated and reported to the physician.

Review of the provider's reviewed 9/30/24 Bathing policy revealed:

Procedure

*-Document bathing activity or refusal of bathing activity. If resident refuses bathing, reapproach resident at a later time or offer another day to bathe the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 435051