Tekakwitha Living Center

F-F689.

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; .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm 49238

Residents Affected - Few Based on observation, interview, record review, and policy review, the provider failed to prevent one of one sampled resident (23) from developing facility-acquired pressure ulcers.

Findings include:

1. Interview on 7/17/24 at 8:00 a.m. with director of nursing (DON) B revealed resident 23 had on heel protectors but wasn't sure the thread in them had not caused his pressure ulcer.

Observation on 7/17/24 at 10:15 a.m. of resident 23 revealed resident 23 was in bed lying on his back when licensed practical nurse (LPN) G went in to provide wound care.

Interview on 7/17/24 at 10:41 a.m. with CNA H in regards to skin concerns revealed:

*She stated, I think the skin issues are from the residents not being repositioned, and she had voiced her concerns to management.

*Administrator A had started rounds and cares had improved.

Interview on 7/17/24 at 12:45 p.m. with administrator A revealed:

*She confirmed that resident 23's pressure ulcers on his sacrum and heel were avoidable, yes, they got to lay him down and get him off that area and he has boots on now.

*She confirmed she had started rounds and things are better.

Interview on 7/17/24 at 2:10 p.m. with LPN G in regard to resident 23's pressure ulcers revealed:

*His sacral pressure ulcer was new in the last 30 days.

*She stated, Yes they were preventable.

*She stated she wondered if the certified nursing assistants (CNAs) knew what floating the heels meant.

*They had changed out his entire bed and mattress a couple of weeks ago because his old one folded him

he indicated like a V with both his head and feet elevated.

*They changed his heel boots to bunny boots.

*They should have changed the interventions for his skin sooner.

*She thought his pressure ulcers were part of his dementia progression.

*There had been some uneasiness among the CNAs playing the blame game in regards to care provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0686 -Administrator A had started doing rounds on the floor and followed up on complaints and things are better.

Level of Harm - Actual harm *She did not work the night shift but the day CNAs did a good job but are rushed at times.

Residents Affected - Few Interview on 7/17/24 at 3:30 p.m. with DON B in regard to resident 23's pressure ulcers revealed:

*His bed was changed to an air mattress because he would slide down in his old one.

*She had placed a 'turn and reposition clock' in his room but the CNAs had taken it down and they would be written up for it but haven't been yet.

*He has bunny boots now because he could feel the thread in the old ones which did not help.

*His heels dug into the sheets when he moved around.

*She agreed his pressure ulcers were avoidable and he should have been given an air mattress sooner.

Observation on 7/18/24 10:45 a.m. of resident 23 with registered nurse (RN) F revealed he was in his bed lying on his back when RN F entered his room to provide wound care.

Review of resident 23's electronic medical record (EMR) revealed his Braden scale for predicting pressure sores was scored at 13 (moderate risk) on 12/7/23 and 12 (high risk) on 7/17/24.

Record review of resident 23's skin observation tool for his right heel pressure ulcer revealed:

*It was discovered on 5/30/24 and measured 0.5 centimeters (cm) by 0.5 cm with no depth measurement noted.

*It was staged at a two (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister).

*It worsened to measure 1.1 by 1.1 cm by 0.1 cm on 6/18/24.

Record review of resident 23's skin observation tool for his sacrum pressure ulcer revealed:

*It was new on 6/20/24 and measured 1.0 cm by 0.6 cm and stage two.

*It was documented on 7/9/24 to have worsened to 7.0 cm by 7.3 cm and stage three (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling).

Review of the provider's undated pressure ulcer prevention and wound care policy revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0686 *General skin care guidelines 1.c. noted, Nursing assistants and staff shall follow the turning schedule as assigned by the charge nurse, observe skin integrity and report changes to charge nurse immediately. Level of Harm - Actual harm -3.a noted, The resident shall be turned and repositioned every 2 hours and as needed, unless Residents Affected - Few 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 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 implement effective precautions and interventions to ensure the safety for one of one sampled resident (10) that contributed to multiple accidents involving woodworking equipment resulting in bodily injury. Specifically, the provider failed to either complete follow-up assessments, incident analysis, or review/revise/monitor interventions.

Findings include:

1. Interview on 7/16/24 at 4:25 p.m. with resident 10 revealed he enjoyed woodworking and had a workshop

in the facility's basement.

Interview on 7/17/24 at 9:41 a.m. with activity director J regarding resident 10's woodworking interest revealed:

*He used a room in the provider's basement as his workshop for his independent woodworking activity.

*She stated that he carried a walkie-talkie with him while he worked in the basement workshop and garage to communicate with staff.

Interview on 7/17/24 at 10:31 a.m. with director of nursing (DON) B regarding resident 10 revealed:

*She stated he had been assessed by the provider's contracted therapy services for his ability to safely pursue his independent woodworking activities.

*She provided the 11/9/23 Occupational Therapy (OT) Evaluation and Plan of Treatment.

*She also provided an undated one-page printed paper titled Care Plan for [resident 10's name] for [NAME] Working.

*When asked regarding ongoing assessments for the resident as he had a diagnosis of Alzheimer's Disease (a brain disease that gets worse over time), she agreed that ongoing assessments were necessary, but stated that since the 11/9/23 OT Evaluation, no other OT evaluation was completed.

*After he had an accident in March 2024, she revealed the electric saw equipment was changed to the current equipment that had an automatic shut-off if a problem was detected.

Interview on 7/18/24 at 9:54 a.m. with social service designee C regarding resident 10's woodworking revealed:

*She agreed he was forgetful at times but stated he was very aware of what he was doing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0689 *He was not doing the woodworking when he was admitted to the facility, but had started his woodworking last fall and she stated that his family was very supportive of his woodworking. Level of Harm - Actual harm *She was aware of the care plan interventions regarding his woodworking but was not sure if staff members Residents Affected - Few supervised him while he used his woodworking saw.

Interview on 7/18/24 at 10:21 a.m. with DON B regarding resident 10 revealed:

*When asked about the care plan intervention that stated he was only to use the electric saw if supervised by

a staff member, she stated

-This does not happen all the time.

-He was aware of the need to be supervised with the electric saw, but will use the saw unsupervised.

-When the staff had a meeting and heard the electric saw in operation, a staff member went down to check

on him.

-He can get agitated with staff as he liked to be independent.

*There was no video camera or alternative method that monitored his workshop activity when staff were not

in supervising him.

Interview on 7/18/24 at 10:25 a.m. with administrator A regarding resident 10's woodworking revealed:

*The maintenance director's office and the provider's laundry area were also located in the basement, and maintenance and laundry staff checked with the resident during the day while they were working.

*He was only to be working in the workshop between 7:00 a.m. and 8:00 p.m.

*He had purchased a new electric saw in March 2024 after an incident had occurred.

-The new saw had a special safety feature that shut off the saw if an error was detected.

-When he was operating the saw, a staff member had to be supervising him.

Observation and interview on 7/18/24 at 10:36 a.m. with resident 10 in his basement workshop revealed:

*He was alone in his basement workshop.

*He had a walkie-talkie on a shelf in his workshop and had his personal cell phone in the front pocket of his overalls.

*When asked how often he used his electric saw, he stated, Maybe once a day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0689 -He stated he had called the maintenance director many times to supervise him while he was operating the electric saw. Level of Harm - Actual harm -He wasn't sure where his safety gloves were that he was supposed to wear when using his electric saw. Residents Affected - Few -He stated At times the staff was busy, and I don't always get someone [when operating the electric saw].

Interview on 7/18/24 at 10:55 a.m. with activity director J regarding resident 10's woodworking revealed:

*She checked in with him throughout the day when she worked.

*He would call me at times when he needed to cut a board on his electric saw.

*She agreed with the safety interventions on his supplemental paper care plan.

*She had no concerns with his woodworking.

An interview on 7/18/24 at 1:36 p.m. with administrator A and DON B regarding the provider's walkie-talkies revealed that multiple staff members, including the administrator, DON, dietary manager, cooks, nurses, medication aides, certified nursing assistants, housekeepers, and maintenance director, had walkie-talkies with them while they worked.

Review of resident 10's electronic medical record (EMR) revealed:

*He moved into the facility on [DATE REDACTED].

*His diagnoses included age-related cognitive decline and Alzheimer's disease.

*A 10/23/23 Health Status progress note at 12:01 a.m. stated At approximately 7:30 pm last evening [10/22/23] resident came to this nurse with his left pointer finger bleeding, resident stated he was working with his table saw and the piece of wood slipped and got his finger, tip of finger noted to be cut off, area cleaned, Bactroban applied and covered with pressure bandage, Dr. [last name of resident's primary physician] and family updated on the above, new orders for Bactroban and dressing daily until healed.

*An 11/9/23 Occupational Therapy (OT) Evaluation and Plan of Treatment documented:

-Diagnoses Age-related cognitive decline.

-Current Referral Reason for Referral: The patient has been referred for a cognitive evaluation s/p [status post] a wood working injury resulting in a cut to digit.

-Background Assessment: Patient Preferences: Hobbies: [NAME] working, making bird houses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0689 -A St. Louis University Mental Status (SLUMS) exam scored at 26 out of a possible 30 indicating Mild Neurocognitive Disorder. Level of Harm - Actual harm -An Assessment Summary that stated .The patient has been performing woodworking tasks for years and Residents Affected - Few resulting [sic] had an accident resulting in a hand injury. The patient was alert and oriented x 4 on this date and did assist with making a safety plan for all his woodworking tasks/tools. Per the SNF [skilled nursing facility], the facility will be placing together a policy to ensure safety during such leisure tasks. The patient is motivated to follow recommendations and continue with his loved leisure task .

Review of resident 10's initial care plan for his woodworking revealed the following interventions:

*OT evaluation related to woodworking safety.

*Orientate and instruct [first name of resident 10] and staff that he will use his cell phone and his pager to call

the staff while in the basement or garage-Relate to anything that [first name of resident 10] may need. Cell Phone Number for [first name of resident 10] [10 digit phone number]

*Attempt to check on [first name of resident 10] often.

*Family aware of woodworking in the basement and aware of the risks of wood working.

*Ventilation in room and wears a mask for dust.

*Make sure that [first name of resident 10] has non-skid shoes while doing wood working.

*[first name of resident 10] is aware to make sure the power switch is off before he plugs into a power tools.

*[first name of resident 10] is aware to not use a tool that is damaged.

*Reminders to [first name of resident 10] to not rush given daily.

*Will continue to update plan with issues as they arise.

*Given to Activities and Nursing Departments on-11/1/23.

Continued review of resident 10's electronic medical record (EMR) revealed:

*An 11/13/23 Daily Charting progress note at 10:30 a.m. stated Skilled OT d/c [discontinued] due to evaluation only 11-9-23 with safety recommendations issued.

*An 11/17/23 Skin/Wound progress note at 9:10 p.m. stated Resident came to nurse's station after working

in his shop, left arm noted to be bloody, resident stated he ran into a piece of wood downstairs, large abrasion to left arm, area cleaned, Bactroban applied and covered with 4X4 Island dressing, Tx [treatment] received to monitor and cover area during the day until healed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0689 *An 11/18/23 Skin/Wound progress note at 9:54 a.m. stated Resident to nurses station, stated that he bumped his Lt. [left] thumb on hood, 1.5 x 1cm open area where skin was off, moderate amount of bleeding Level of Harm - Actual harm due to blood thinners. Tx. [treatment] received for cleanse with betadine, apply bactroban and dressing daily until healed. Residents Affected - Few *No follow-up assessment or incident analysis had been documented in the resident's EMR for the 11/17/23 incident or the 11/18/23 incident.

Review of resident 10's 11/23/23 woodworking care plan revealed an intervention had been added that stated Will Wear safety gloves .

Continued review of resident 10's electronic medical record (EMR) revealed:

*A 3/16/24 Incident progress note at 12:00 noon stated Resident called for help from basement work room and was assisted by med [medication] aide who entered to find resident with left hand wrapped in a bloody paper towel. Med [medication] Aide brought resident upstairs to nurses station. Resident is alert and oriented and conversing and answering questions appropriately. Moderate amount of blood covering hand. Noted deep, jagged cuts to 2nd, 3rd and fourth fingers. Immediately placed 4x4's and wrapped generously with kerlix, elevated the extremity. Resident placed call to his Grandson at this time and transport to CDP [Coteau des Prairies] ER [emergency room ] was arranged.

*A 3/16/24 progress note at 2:00 p.m. stated Resident returned from CDP [Coteau des Prairies] ER [emergency room ] at this time. The affected fingers are wrapped. Resident states 20 stitches total. Written Orders Received: Wash the laceration with peroxide and apply and antibiotic ointment twice a day. Dr. [last name of resident's primary physician] to remove stitches on 03/28/24.

*No follow-up assessment or incident analysis had been documented in the resident's EMR for the 3/16/24 incident.

Review of resident 10's 3/24/24 woodworking care plan revealed an intervention had been added that stated Can only saw if he is supervised with a staff member.

Continued review of resident 10's electronic medical record (EMR) revealed:

*A 6/19/24 Skin/Wound progress note at 12:10 a.m. stated Resident rang call light at this time to ask to see

the nurse, when nurse entered room resident was sitting in his recliner with shirt off and abdomen exposed, nurse noted a large bruise to the right side of abdomen that measured 5 in [inches] X 3 in [inches] with a small gash in the middle, resident then turned and showed nurse his left side of abdomen and nurse noted large bruise with scrape running through the middle of the bruise, area measures 10 in [inches] X 5 in [inches], both sides were cleaned and antibiotic ointment was applied to open area on right abdomen and then covered with 4x4 island dressing, resident denies pain to areas when asked, he states he was using his saw in his work shop and it kicked the boards back at him and hit his abdomen a few times, when asked about how long ago this happened and resident stated around 8 pm tonight [6/18/24], resident offered a cold pack and Tylenol but interventions were refused.

*No follow-up assessment, incident analysis or review/revision of current interventions was documented in

the resident's EMR for the 6/18/24 incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0689 *A recently completed Brief Interview for Mental Status (BIMS) exam on 7/12/24 was scored at 10 out of a possible 15 indicating he was cognitively moderately impaired. Level of Harm - Actual harm

Review of the provider's undated policy on Resident safety during leisure tasks revealed: Residents Affected - Few *Policy Statement: Resident will be free from accidents and hazards while doing leisure tasks.

*Accidents and Supervision.

-[Name of provider] will ensure that the resident's environment will be free from accidents and hazards over which the facility has control to prevent avoidable accidents and will provide supervision and assistive devices to each resident. This will include identifying, evaluating, analyzing and then implementing interventions to reduce hazards and risks and then monitoring for effectiveness and then modifying interventions if necessary.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49238 Residents Affected - Some Based on observation, interview, and policy review, the provider failed to ensure expired medications were removed from one of one medication room, one of two medication carts, and one of two treatment carts.

Findings include.

1. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0761 Review of the provider pharmacy 5/29/24 and 6/27/24 audits revealed that outdated medications were not part of their audit. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45683

Residents Affected - Some Based on observation, interview, record review, and policy review, the provider failed to ensure:

*Necessary food safety guidelines were followed for appropriate storage and labeling of food items in one of one main kitchen.

*Proper temperature documentation was completed for three of three refrigerators and three of three freezers in the main kitchen.

Findings include:

1. Observation on 7/15/24 at 5:11 p.m. during the initial tour of the main kitchen revealed:

*The document posted on the walk-in refrigerator was titled sanitation/record of refrigerator temperatures.

*The document had six columns labeled:

-Walk-in cooler.

-Walk-in Freezer.

-Reach-in Freezer.

-Cooks cooler.

-Reach-in Juice cooler.

-Unlabeled.

*The documentation was missing for at least five days in July for all six columns of the temperature record.

Interview on 7/16/24 at 11:52 a.m. with cook I in the kitchen revealed:

*He agreed the sanitation/record for refrigerator and freezer temperatures should have been filled out daily.

*Staff were educated on refrigerator and freezer documentation on a regular basis.

*He confirmed he had not documented the temperatures for his last two shifts.

Record review and interview on 7/17/24 at 2:18 p.m. with dietary manager D regarding the sanitation/record of refrigerator temperatures revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0812 *The April, May, and June 2024 sanitation/record of refrigerator temperature logs were each missing several days of documentation for temperatures. Level of Harm - Minimal harm or potential for actual harm *She had provided education to staff for temperature documentation.

Residents Affected - Some *Her expectation was that staff would document refrigerator and freezer temperatures daily.

*She had given verbal warnings to staff that had not completed documentation.

*She agreed staff were not documenting refrigerator and freezer temperatures.

Review of the provider's undated refrigerator/freezer temperature monitoring policy revealed:

*Temperatures of all freezers and refrigerators will be monitored daily.

*4. All unit temperatures are to be recorded daily on the Record of Refrigeration Temperatures form. Records of forms will be maintained for 6 months.

50916

2. Observation on 7/15/24 from 5:11 p.m. to 6:10 p.m. during the initial main kitchen tour revealed:

*There was a metal shelving unit which held the following improperly stored and labeled food items:

-Opened powdered sugar in the original package, closed with a twisty tie, and no use by date.

-Opened bag of Rice Krispies, closed with a twisty tie, and no use by date.

-Opened spice cake mix with no use by date.

-Cinnamon rolls in metal baking pan, covered with plastic wrap, and no use by date.

-Marshmallows in a plastic container with no use by date.

*Outdated food items in one of two refrigerators:

-Bag of chopped chicken dated 3/20/24, closed with a twisty tie.

-Sausage patties and links with no use by date, closed with a twisty tie.

-Coleslaw in a metal bowl covered with plastic wrap and handwritten date of 7/9.

-Meatloaf in plastic container with handwritten date of 7/9

-Opened turkey breast in original package with handwritten date of 7/7.

-Roast beef slices in zip lock bag with handwritten date of 6/7.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0812 -Chicken salad in metal bowl covered with plastic wrap and handwritten date of 7/3.

Level of Harm - Minimal harm or *Uncovered food items in one of two refrigerators: potential for actual harm -Pumpkin pie with one slice missing. Residents Affected - Some -Butterscotch pudding dished into individual serving cups and placed on serving tray.

-Sliced cheese on a tray.

3. Interview and observation on 7/17/2024 at 2:06 p.m. with dietary manager D in the main kitchen regarding food storage and labeling revealed:

*She tossed the uncovered pie with no date on it into the trash and stated it should have been covered and thrown out by now.

*She threw away outdated items in one of two refrigerators including the roast beef, chicken salad, and sausage.

*She stated food items in the fridge are only good for seven days and everything should have been covered, dated, and thrown away if outdated.

4. Interview on 7/18/2024 at 12:05 p.m. with administrator A about expectations on food storage and labeling revealed:

*Her expectations were that staff will throw away outdated items.

*The staff should keep food items covered and and date them accordingly.

5. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 49238 potential for actual harm Based on observation, interview, record review, and policy review, the provider failed to ensure appropriate Residents Affected - Some infection control measures were followed by two of two nurses licensed practical nurse (LPN) G and registered nurse (RN) F for pressure ulcer dressing changes.

Findings include:

1. Observation and interview on 7/17/24 at 10:15 a.m. of resident 23's wound care with LPN G revealed she:

*Stated he was on enhanced barrier precautions (EBP) (precautions to prevent transmission of infectious agents) due to his wounds.

*Prepared for the resident's wound care at the nurses' station.

*Poured Vashe wound solution into a med cup and placed a gauze in the cup without gloves and placed it on top of the treatment cart.

*Opened the Mepilex sacral dressing package, placed it on its wrapper and wrote the date on it with a marker and placed it top of the treatment cart.

*Pushed the wound treatment cart down the hall and into the resident's room.

*Confirmed the resident did not have a dressing on his sacrum when the certified nursing assistants (CNA's) H and K removed his brief.

*Cleaned bowel movement from the area.

*Changed her gloves but did not wash her hands or use hand sanitizer.

*Sprayed the wound with wound cleanser and changed her gloves but did not wash her hands or use hand sanitizer.

*Applied the gauze that had been soaked in Vashe wound solution to the wound.

*Covered the wound with the Mepilex sacral dressing.

*Removed her gloves and washed her hands.

*Cleaned the wound cart and hard-surfaced items used and removed the cart from the resident's room.

Observation and interview on 7/18/24 at 10:45 a.m. of resident 23's heel dressing change with RN F revealed she:

*Confirmed he was on EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 *Entered his room with the wound treatment cart.

Level of Harm - Minimal harm or *Removed the bunny boot and sock from his right foot. potential for actual harm *Confirmed he did not have a dressing on his heel wound. Residents Affected - Some *Did not change her gloves or wash her hands after she removed his boot and sock.

*Sprayed the wound with dermal wound cleanser and placed a foam Tegaderm dressing on the wound.

*Removed her gown and gloves, wiped down the treatment cart and items she had used prior to pulling the cart out of the room and into the hall.

*Confirmed the resident was on EBP due to his wound.

*Was not sure if she should have taken the wound treatment cart into the room for a resident on EBP, but that is was what she was used to doing.

*Agreed she should have changed her gloves and washed her hands after removing his boot and sock

before applying the new dressing to his heel wound.

Interview with DON B on 7/18/24 at 3:30 p.m. related to infection control in regards to dressing changes and wound care revealed:

*She was frustrated that the nurses had not performed hand hygiene appropriately during wound care.

*She stated, Hand hygiene during wound care was standard care and they had been educated about this frequently.

*She stated there was nothing to say but the treatment cart should not have gone into the resident's room as resident 23 was on EBP.

Review of the provider's undated pressure ulcer prevention and wound care policy revealed wound care for dressing changes indicated that nurses should have used clean (meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves, and prevention of direct contamination of materials and supplies).

Review of the providers undated enhanced barrier precautions policy revealed:

*The provider would have implemented barrier precautions for the prevention of transmission of multidrug-resistant organisms.

*The definitions noted Enhanced barrier precautions were an infection control intervention designed to reduce transmission or multidrug-resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involved gown and glove use during high-contact resident care activities for residents known to be colonized (germs are on the body but do not make you sick) or infected with a MDRO as well as those at increased risk of MDROs acquisition (ex: residents with wounds or indwelling medical devices).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 -Wound in relation to this guidance, this generally had included residents with chronic wounds, and not those with shorter -lasting wounds, such as skin breaks or skin tears covered with a Band-Aid or similar dressing. Level of Harm - Minimal harm or Examples of chronic wounds include but are not limited to, pressure ulcers diabetic foot ulcers, unhealed potential for actual harm surgical wounds and chronic venous stasis ulcers.

Residents Affected - Some *Wound care would be any skin opening requiring a dressing would have been considered a high 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 435038 Department of Health & Human Services Printed: 09/17/2025 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 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

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 49238

Residents Affected - Many Based on interview and record review, the provider failed to have a qualified infection preventionist for the facility.

Findings include.

1. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 435038