Strand-kjorsvig Community Rest Home

F-F865.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45683 potential for actual harm Based on observation, interview, record review, and policy review, the provider failed to ensure enhanced Residents Affected - Some barrier precautions (EBP) were followed according to the provider's policy for two of two sampled residents (25 and 79) on EBP.

Findings include:

1. Observation and interview on 5/6/25 at 9:08 a.m. with resident 79 in her room revealed:

*A sign on her door stated she was on EBP and included the following:

-Everyone must clean their hands, including before entering and when leaving the room.

-Providers and staff must also wear gloves and a gown for the following high-contact activities:

--Dressing.

--Bathing/showering.

--Transferring.

--Changing linens.

--Providing Hygiene.

--Changing briefs or assisting with toileting.

*Device care use:

-Central line, urinary catheter, feeding tube, tracheostomy.

-Wound care: any skin opening requiring a dressing.

*There was no personal protective equipment (PPE) (gowns, gloves, and/or protective eyewear) available for use on or near the door.

*She was not sure why the sign was on her door.

Review of resident 79's EMR regarding EBP revealed:

*She was readmitted on [DATE REDACTED] following a hospital stay for a procedure.

*She had an incision with staples from that procedure, with a physician's order to keep the area clean and dry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 *There was nothing identified in her EMR that indicated the need for EBP.

Level of Harm - Minimal harm or 2. Interview on 5/7/25 with certified nursing assistant (CNA) L at 2:15 p.m. regarding the EBP sign on potential for actual harm resident 79's door revealed:

Residents Affected - Some *Resident 79 had returned from the hospital on Monday (5/5/25).

*She was unsure why the EBP sign was on the resident's door.

*Staff were to wear a gown and gloves when providing her care if she was on EBP.

*Gowns were kept in the bottom drawer of the resident's dresser.

*The nurse would inform the staff if there were any changes in infection control for residents so they would know what PPE to wear when caring for the residents.

51472

3. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed:

*There was a sign on the outside of his door to his room that indicated he was on EBP.

*There was no PPE available for use on his room door or near the room's entrance.

*He stated he was at the facility to receive therapy services and planned to return home after his therapy was completed.

*He indicated he had a surgical wound on his right lower leg that required a daily dressing change.

*He stated the staff wore gloves when they changed his dressing and assisted him with cares, but they did not wear a gown.

*He was not aware of any gowns being stored in or near the entrance to his room.

Review of resident 25's EMR revealed:

*He was admitted on [DATE REDACTED].

*He had a BIMS assessment score of 15, which indicated he was cognitively intact.

*There was a physician's order that indicated, Right ankle apply Silvadene [a topical antimicrobial cream] and change dressing daily. one time a day for surgical site. related to DISPLACED FRACTURE OF LATERAL MALLEOLUS OF RIGHT FIBULA [right ankle fracture].

Review of resident 25's care plan revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 *An intervention for Enhanced Barrier Precautions (EBP) to be used when providing cares for [resident 25]. EBP includes ABHR [alcohol-based hand rub] to hands before entering and when leaving the room. Level of Harm - Minimal harm or PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident potential for actual harm Care Activities: when caring for [resident 25's] left ankle wound, assisting him with dressing, undressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with Residents Affected - Some toileting.

*Resident 25's care plan indicated he required assistance from one staff for showering, dressing, toileting, and transferring.

4. Interview on 5/6/25 at 4:47 p.m. with certified nursing assistant (CNA) Q revealed:

*Residents were on EBP if they had catheters or wounds.

*She usually only wore gloves when providing resident cares for residents on EBP.

*She indicated she had previously worn gowns but was no longer was required to because the wounds (in relation to all residents on EBP for wounds) were covered.

5. Observation on 5/7/25 at 8:28 a.m. of resident 25 in the therapy area revealed:

*No staff in the therapy area were wearing a gown or gloves.

*Physical therapy assistant (PTA) P placed a gait belt on resident 25, assisted him to a standing position, and walked with him with a walker, and providing continuous contact assistance without wearing any PPE.

6. Interview on 5/7/25 at 9:36 a.m. with PTA P revealed:

*She had been provided education related to EBP.

*She was aware of which residents required EBP by the sign that was posted on the resident's room door.

*She thought she only needed to wear PPE for EBP is she was in the resident's room and had not worn PPE

in the therapy area while she provided therapy services for the resident.

7. Interview on 5/7/25 at 10:02 a.m. with licensed practical nurse (LPN) I revealed:

*Residents with catheters, wounds, and certain infections required EBP.

*The gowns were stored in the closets in the resident rooms.

*She would put on a gown as soon as she entered the room to provide cares for residents on EBP.

8. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed:

*She was the infection preventionist (IP) for the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 *A gown and gloves were to be worn when providing direct resident care for residents with wounds, catheters, and the residents who had multidrug-resistant organisms (MDRO), which would require the Level of Harm - Minimal harm or resident to be on EBP. potential for actual harm *The same PPE required for in-room care for residents on EBP was to be worn in the therapy area for those Residents Affected - Some residents.

*She had not thought of providing a PPE supply to be available for use in the therapy area.

*It was her expectation that all facility staff and therapy staff followed the requirements for EBP.

9. Review of the provider's February 2025 Enhanced Barrier Precaution Policy revealed:

*EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices).

-High-contact resident activities include:

--Dressing

--Bathing/Showering

--Transferring

--Providing Hygiene

--Changing linens

--Changing briefs or assisting with toileting

--Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator

--Wound care: any skin opening requiring a dressing

*Enhanced Barrier Precautions should be followed when performing transfers and assisting during bathing in

a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 51472 potential for actual harm Based on interview, policy review, and record review, the provider failed to implement an effective antibiotic Residents Affected - Some stewardship program according to their policy related to:

*Ensuring residents' symptoms were present and documented prior to contacting their physicians related to potential infection.

*Reviewing infections and antibiotics for possible trends.

*Completing and annual summary of antibiotic use in the facility and reporting that to the QAPI committee.

*Having an antibiogram (a table that shows which antibiotics are most likely to be effective against specific bacteria) done every 18-24 months to guide development or revision of antibiotic use protocols.

*Following up annually with physicians regarding antibiotic use for residents.

Findings include:

1. Interview on 5/8/25 at 9:34 a.m. with director of nursing (DON) C regarding the facilities antibiotic stewardship program and policy revealed:

*She was the infection preventionist for the facility and was in charge of the antibiotic stewardship program.

*The facility used a situation-background-assessment-recommendation (SBAR) form that was based off McGeer criteria for infection surveillance and monitoring.

*The SBAR form was used for suspected respiratory, urinary, and soft tissue infections of the residents.

*DON C stated the facility was not 100% compliant with the use of the SBAR form when a resident had symptoms of urinary tract infections because she felt they [the staff] know when a resident had a change in their health status.

*When asked what not 100% compliant meant she stated the facility was noncompliant almost always.

*She stated if the staff waited for all the symptoms required with the criteria on the SBAR form to obtain a urinalysis (UA) order from the physician then the resident would have been more ill than if the urinary tract infection (UTI) was identified earlier.

*DON C stated she had discussed this with medical director N and at times medical director N would refuse

the order request for a UA by stating the resident required more symptoms for a UA to be ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 0881 *DON C was responsible for ensuring the facility received all lab and other diagnostic testing results that had been ordered at the facility and following up with the resident primary physician regarding the results. Level of Harm - Minimal harm or potential for actual harm *She tracked the facility's use of antibiotic by printing out a report that was provided by the facility's contracted pharmacy that listed the antibiotics used by residents for the dates selected when the report was Residents Affected - Some run.

-That report included the resident name, the name of the antibiotic or antifungal medication with the instructions for use, when the medication was dispensed, when the medication was started, and the number of days the medication was administered.

-That report did not include the diagnosis or indication for use of the medication, if the antibiotic was determined appropriate or necessary upon the receipt of the results of the diagnostic testing had been received.

*She did not monitor infections related to the resident's location within the facility to identify potential clusters of residents with infections.

*The only tracking she completed related to illness and antibiotic use was reviewing the monthly antibiotic use that was documented in the report provided by the facilities contracted pharmacy during the monthly Quality Assurance and Performance Improvement (QAPI) meeting after she removed the antibiotics that were taken by residents for the prevention of infections from the report.

Continued interview and review of the provider's 3/22/18 Antibiotic Stewardship Program policy with DON C revealed:

*She had not been following the policy in the following areas:

-She talked about the antibiotic use monthly but did not complete an annual summary.

-There were no antibiotic stewardship meetings held as the facility policy indicated.

-She did not complete random audits for resident's antibiotic use.

-She did not track one outcome measure associated with antibiotic use monthly.

-The facility did not have an antibiogram to review.

-She did not follow up with the prescribing physicians annually regarding their use of antibiotics for the residents.

Continued interview on 5/8/25 at 11:30 a.m. with DON C revealed she was not aware that the facilities infection rate for UTIs for long-stay residents was above the state and national average according to the facilities reported quality measures.

2. Review of the providers 3/22/18 Antibiotic Stewardship Program policy revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 0881 *It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of Level of Harm - Minimal harm or infections while reducing the adverse events associated with antibiotic use. potential for actual harm *The program includes antibiotic use protocols and a system to monitor antibiotic use. Residents Affected - Some -a. Antibiotic use protocols:

--i. Nursing stall shall assess residents who are suspected to have an infection and complete a Medical Care Referral Form prior to notifying the physician.

--ii. Laboratory testing shall be in accordance with current standards of practice.

--iii. The facility uses the (CDC's [Center for Disease Control] NHSN [National Healthcare Safety Network] Surveillance Definitions) to define infections.

--iv. The Loeb Minimum Criteria are used to determine whether or not to treat an infection with antibiotics.

*Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure).

*At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include: tracking C. difficile infections, antibiotic resistance, or adverse drug events related to antibiotic use.

*At least annually, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical and nursing staff, and the QAA [quality assessment and assurance] Committee.

*A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices.

*At least annually, each attending physician shall be provided feedback on his/her antibiotic use data in the form of a written report.

*Documentation related to the program maintained by the Infection Preventionist, including but not limited to:

-a. Action plans and/or work plans associated with the program.

-b. Assessment forms.

-c. Antibiotic use protocols/algorithms.

-d. Data collection forms for antibiotic use, process, and outcome measures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 0881 -e. Antibiotic stewardship meeting minutes.

Level of Harm - Minimal harm or -f. Feedback reports. potential for actual harm -g. Records related to education of staff, residents, and families. Residents Affected - Some -h. Annual reports.

Review of the provider's 10/12/17 Infection Reporting policy revealed The Infection Preventionist will report findings of surveillance activities, including at a minimum incident rates and types of infections, to the QAA committee, physicians, and other appropriate staff.

3. Review of the provider's March 2025 Facility Assessment revealed:

*We track and trend infections.

*We have monthly infection control meetings and quarterly QAPI meetings with our medical director, consulting pharmacist and Leadership team to discuss any issues.

*We have developed an Antibiotic Stewardship Policy and Procedure and have educated our staff, medical providers, pharmacy consultant, residents and their families.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 51472

Residents Affected - Some Based on interview, and record review, the provider failed to ensure that one of one designated infection preventionist (director of nursing C) had completed specialized training in infection prevention and control.

Findings include:

1. Interview on 5/8/25 at 9:34 a.m. with director of nursing (DON) C revealed:

*She was the designated infection preventionist for the facility.

*She was haired on 10/7/21.

*She had started the Center for Disease Control's (CDC) specialized infection prevention and control training, Nursing Home Infection Preventionist Training course, in October 2022.

*She did not have a certification of completion for the Nursing Home infection Preventionist Training Course.

*She was not aware that she had not completed the entire course.

Record review of DON C's certificates of completion of modules of the CDC's Nursing Home Infection Preventionist Training Course revealed:

*Module 1- Infection Prevention and Control Program with a completion date of 10/5/22.

*Module 2- The Infection Preventionist with a completion date of 10/5/22.

*Module 3- Integrating Infection Prevention and Control into the Quality Assurance Performance Improvement Program with a completion date of 10/5/22.

*Module 4- Infection Surveillance with a completion date of 10/5/22.

*Module 5- Outbreaks with a completion date of 10/5/22.

*DON C had not completed 18 of the 23 modules required for completion of that course.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 60 435125

F-F882.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 49958 potential for actual harm Based on interview, record review, and policy review, the provider failed to ensure the quality assessment Residents Affected - Many and assurance (QAA) committee had included the required members of at least one of who was the administrator, owner, a board member, or other individual in a leadership role. The provider had no evidence of the administrator, owner, board member, or other designee having attended QAA meetings at least quarterly for 15 months of meeting attendance records reviewed (February 2024 through May 2025).

Findings include:

1. Interview on 5/7/25 at 10:49 a.m. with medical director (MD) N regarding the provider's QAA and Quality Assessment and Performance Improvement (QAPI) meetings and program revealed:

*She attended QAPI meetings quarterly and did not recall seeing administrator A present at those meetings routinely.

*She was unaware of how often administrator A was at the facility or how often he attended the QAPI meetings in the past two years.

*She expected that the administrator would be involved in identifying and correcting areas of concern identified in the QAPI program.

-She indicated the facility could use his support.

2. Interview on 5/8/25 at 11:22 a.m. with director of nursing (DON) C regarding QAA and QAPI revealed:

*She was responsible for overseeing the facility's quality management program, including QAA committee meetings and QAPI projects.

*The QAA committee was expected to meet monthly.

*The provider's QAPI committee was comprised of department managers and DON C.

*The medical director and the consultant pharmacist attended QAPI meetings quarterly.

*Administrator A attended the QAPI meeting that week for the first time in quite a while.

*Administrator B had been at the facility approximately three hours a week for the last couple of months, but

she had not attended a QAPI meeting.

*She had requested that another QAA member be assigned the responsibility for overseeing the QAPI program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 60 435125 Department of Health & Human Services Printed: 08/27/2025 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 435125 B. Wing 05/08/2025

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

Strand-Kjorsvig Community Rest Home 801 S Main Roslyn, SD 57261

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 0868 3. Review of the provider's previous 15 months of monthly QAPI Meeting Attendance records revealed:

Level of Harm - Minimal harm or *Between 2/13/24 and 5/6/25, administrator A attended two QAPI meetings. potential for actual harm -He attended on 6/25/24 and 5/6/25. Residents Affected - Many *None of the meetings were attended by the owner, a board member, or another individual in a leadership role.

Review of the providers' reviewed 12/1/23 QAPI plan policy revealed:

*Governance and Leadership:

-The governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program and for: 1) Identifying and prioritizing problems based on performance indicator data. 2) Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents. 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 4) Setting clear expectations for safety, quality, rights, choice, and respect. 5) Ensuring adequate resources exist to conduct QAPI efforts.

*The QAPI program will be structured to incorporate input, participation, and responsibility at all levels. The Governing Body and QAPI Committee of the nursing center will develop a culture that involves leadership-seeking input from nursing center staff, residents, their families, and other stakeholders; encourages and requires staff participation in QAPI initiatives when necessary; and hold staff accountable for taking ownership and responsibility of assigned QAPI activities and duties.

*QAPI Committee Members were listed as: Medical Director, Director of Nursing, Administrator, Infection Control Officer, Environmental Manager, Activities Director, Social Services Designee, Dietary Manager, and Business Manager.

Refer to