Tekakwitha Living Center
TEKAKWITHA LIVING CENTER in SISSETON, SD — inspection on July 18, 2024.
Found 9 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
Review of the provider's undated Bed Hold Policy and Notification revealed: *Bed Hold Policy was given on date of admission in the admission binder booklet. *It stated what hospitalization and therapeutic leave was and the general rules for holding and paying for a bed. *It had not stated when the bed hold policy notification was to be given to the resident and/or their representative.
435038 07/18/2024
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
for each resident.
levels; .i. reflect currently recognized standards of practice for problem areas and conditions.
-9.
The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans; .b.
When the desired outcome is not met; .
schedule as assigned by the charge nurse, observe skin integrity and report changes to charge nurse immediately. -3.a noted, The resident shall be turned and repositioned every 2 hours and as needed, unless contraindicated. *General pressure ulcer management guidelines 1.
Noted, the RN/LPN shall initiate Pressure Ulcer Management Guidelines for at risk resident on admission and/or later if the resident condition warrants.
435038 07/18/2024
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
hazards over which the facility has control to prevent avoidable accidents and will provide
and then implementing interventions to reduce hazards and risks and then monitoring for
A request for resident 10's incident reports related to his woodworking was made on 7/18/24 at 10:20 a.m. from administrator A and no incident reports were received by the end of the survey.
435038 07/18/2024
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
Based on observation, interview, and policy review, the provider failed to ensure expired medications
treatment carts.
Findings include.
- Observation and interview on 7/18/24 at 10:00 a.m. of the provider's north hall medication room,
medication cart, and treatment cart with registered nurse (RN) F revealed: *Two of seven containers of stock aspirin enteric coated 25 milligram (mg) had expired in April 2024. *Eight of eight hydrogen peroxide had expired in April 2023. *Three of three isopropyl rubbing alcohol 70 % had expired in March 2023. *Two of two tubes of oral glucose gel had expired in October 2023. *Three of three Heparin injectable syringes had expired in December 2023. *Five of five Prevnar 13 (pneumococcal vaccine) injectable had expired in September 2023. *One of one bottle of Aalcare hand sanitizer had expired in March 2024. *Thirty two of thirty six packets of white petroleum had expired in 2019. *Six of six packets of Vaseline gauze six of six had expired in June 2022. *She stated medication expiration dates would have been checked before administering to a resident and should have been removed.
Interview on 7/18/24 at 3:30 p.m. with director of nursing (DON) B revealed: *She had not been able to keep up with removing expired medications from the medication rooms and carts but should have been removed and destroyed. *She confirmed the pharmacy audits were completed but their audits did not include expired medications.
Review of the provider's undated storage of medications policy revealed 4. NO discontinued, outdated, or deteriorated drugs or biologics are available for use in the facility, All such drugs are destroyed.
Review of the provider pharmacy 5/29/24 and 6/27/24 audits revealed that outdated medications were not part of their audit.
435038 07/18/2024
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
Review of the provider's 2013 Food Storage policy Procedure revealed: *4.
Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods.
All containers must be legible and accurately labeled and dated. *13.
Leftover food is stored in covered containers or wrapped carefully and securely.
Each item is clearly labeled and dated before being refrigerated.
Leftover food is used within three days or discarded. *14.
Refrigerated Food Storage: -f.
All foods should be covered, labeled, and dated.
All foods will be checked to assure foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
435038 07/18/2024
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers.
contact resident activity.
*General considerations indicated, enhanced barrier precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for contact precautions, even if they had no history of MDRO colonization.
This was because devices and wounds are risk factors that would have placed these residents at high risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized.
435038 07/18/2024
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
program in the nursing home.
for the facility.
Findings include.
- Interview on 7/15/24 at 6:05 p.m. with administrator A revealed:
*Director of nursing (DON) B was the infection preventionist (IP). *DON B had not been trained as an IP but had been completing some of the tasks. *The provider had not had an IP for at least two years.
Interview on 7/18/24 at 3:30 p.m. with DON B revealed she: *Had been acting as the facility's IP the last two years. *She had not signed off as an IP because she had no training or certification as an IP. *They had tried to get one of their registered nurses to take the program but it had not worked out for them.
Record review of the providers infection control program revealed: *The provider did not have an IP. *The annual review signature form had not been signed by an IP for at least two years.
435038 07/18/2024
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
Review of the provider's undated policy on Care Plans - Comprehensive revealed:
*Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.
*3.g.
Aid in preventing or reducing declines in the resident's functional status and/or functional levels; .i. reflect currently recognized standards of practice for problem areas and conditions.
-9.
The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans; .b.
When the desired outcome is not met; .
435038
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 435038 B.
Wing 07/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Tekakwitha Living Center 6 E Chestnut Sisseton, SD 57262
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.