Strand-kjorsvig Community Rest Home
Strand-Kjorsvig Community Rest Home in ROSLYN, SD — inspection on May 8, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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] 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.
435125
Form Approved OMB
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
Review of the provider's previous 15 months of monthly QAPI Meeting Attendance records revealed:
potential for actual harm -He attended on 6/25/24 and 5/6/25.
*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