Bethesda Of Beresford

In the surveyor’s words

From the most serious findings on record at Bethesda Of Beresford, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 4, 2023

  Based on review of a South Dakota Department of Health facility incident report, interview, observation, policy review, and document review, the provider failed to develop and implement an effective training and orientation program for five of seven certified nurse assistants (CNAs) (C, E, F, G, and H) that might have contributed to an accident involving a full-body mechanical lift falling on top of one of one sampled resident (1) resulting in bodily injury. Findings include: 1. […]

• Actual harm, isolatedF686Oct 7, 2021

  Based on observation, interview, record review, and policy review, the facility failed to ensure two of two sampled residents (15 and 34) with facility acquired pressure ulcers and one of one sampled resident (35) with a history of pressure ulcers had: *Ongoing skin assessments. *Implemented individualized interventions to prevent skin injuries. *Updated care plans for the prevention of pressure ulcers. Findings include: 1. Observations on the following dates and times of resident 34 revealed on: *10/5/21 at: -9:16 a.m. she was lying on her back in bed, both eyes were closed, the head of the bed was elevated 25 degrees, and she had pressure relieving boots on both feet. -12:43 p.m. […]

• Actual harm, isolatedF688Oct 7, 2021

  Based on observation, interview, and record review, the provider failed to ensure 3 of 14 sampled residents (9, 31, and 34) had received an ongoing restorative program. Findings include: 1. Observation on 10/5/21 at 10:42 a.m. of resident 31 in his room revealed he was in his Broda chair with the TV on. He was alert and appeared to focus on the TV program, but only responded verbally with a yeah or no to questions. Surveyor asked the resident to open and close his left hand and the resident responded appropriately by closing his left hand into a fist and opening it. Surveyor asked the resident to open and close his right hand, but the resident did not close or open his right hand. Resident's right hand appeared contracted. […]

• No harm, potential for more than minimal, widespreadF725Apr 25, 2024

  Based on observation, interviews, record review, and policy review, the provider failed to ensure there were sufficient nursing staff to ensure call lights were answered in a reasonable time for five of thirty-five sampled residents (3, 4, 5, 13, and 21). Findings include: 1. Interview on 4/23/24 at 10:29 a.m. with resident 4 in his room revealed he: *Pointed out his pendant call light and stated its function. *Mentioned that sometimes he had to wait 20 to 30 minutes for someone to answer the call light. *Did not use the call light frequently. Review of resident 4's call light audit report from 2/24/24 to 4/24/24 revealed: *The report was generated from 2/24/24 to 4/24/24, but there was no data on the report before 4/5/24. *There were three call light wait times over 15 minutes. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based on observation, interview, record review, and policy review, the provider failed to ensure necessary food safety guidelines were implemented and followed for appropriate storage and labeling of food and chemical items, appropriate monitoring of the low-temperature dishwasher, and cleaning and sanitary maintenance of one of one kitchen. Findings include: 1. Observation on [DATE] at 8:26 a.m. during the initial kitchen tour revealed: *There were approximately 35 cans of fruits and vegetables in the dry storage room with no manufacturer's date and no date when those food items were received. *There were four dented cans in the dry storage room. […]