Eastern Star Home of South Dakota, Inc

In the surveyor’s words

From the most serious findings on record at Eastern Star Home of South Dakota, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF812Jul 18, 2024

  Based on observation, interview, record review, and policy review, the provider failed to maintain the dishwasher wash cycle temperature at a minimum of 120 degrees Fahrenheit per the manufacturer's manual for one of one dishwasher. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen. Findings include: 1. Observation and interview on 7/17/24 at 10:58 a.m. with cook G in the kitchen revealed: *The wash cycle temperatures on The Dishwashing Machine Temperature log was recorded as follows: -7/13/24 Breakfast 100 degrees Fahrenheit, dinner 112 degrees Fahrenheit, supper 108 degrees Fahrenheit. -7/14/24 Breakfast was left blank, dinner 106 degrees Fahrenheit, supper was left blank. […]

• Actual harm, isolatedF689May 5, 2026

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure an environment free from accident hazards by one of one certified nursing assistant (CNA)/bath aide (E) who did not use the required whirlpool chair safety belt while providing a whirlpool bath for one of one sampled resident (1) who subsequently fell out of the whirlpool chair onto the floor, which caused laceration to the resident's forehead that required sutures. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. […]

• No harm, potential for more than minimal, patternF657Jul 18, 2024

  Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were revised to reflect the current enhanced barrier precautions (EBP) of eight of twenty sampled residents (1, 3, 6, 19, 21, 23, 27, and 28). Findings include: Refer to F880. Interview on 7/18/24 at 11:34 a.m. with Minimum Data Set (MDS)/infection preventionist (IP) C revealed: *It was her responsibility to complete the care plans. -Care plans were completed on admission, quarterly, and whenever things change. *She expected EBP to have been on the care plans, and a sign to have been on the doors to inform staff of residents with catheters, indwelling feeding tubes, and open wounds. *She confirmed that the care plans had not been updated to indicate EBP for any residents. […]

• No harm, potential for more than minimal, patternF880Jul 18, 2024

  Based on observation, interview, and policy review the provider failed to ensure: *One of one sampled resident (10) who was on precautions for Clostridium Difficile (C-Diff) had their room cleaned with bleach by one of one housekeeping staff (K). *Eight of eight sampled residents (1,3,6,19,21,23,27, and 28) had been placed on enhanced barrier precautions (EBP). 1. Observation of resident 10's door to her room revealed there was a red P and a drawered storage container that contained personal protective equipment (PPE). Interview on 7/16/24 at 9:00 a.m. with medication aide/certified nursing assistant (CNA) M regarding precautions for resident 10 revealed she had C-Diff. Interview on 7/16/24 at 9:30 a.m. […]

• No harm, potential for more than minimal, patternF604Sep 16, 2021

  Based on observation, interview, record review, and policy review, the provider failed to ensure four of four sampled residents (14, 17, 24, and 28) had been assessed for the use of a scooped mattress and chair and/or bed alarms as restraints or enablers. Findings include: 1. Observation on 9/14/21 at 10:30 a.m. revealed resident 17 in her wheelchair at the beauty shop with an chair alarm cord clipped to her collar. Further observation on 9/15/21 of resident 17 at the following times revealed: *8:00 a.m.: -Not in her room, a bed alarm pad was draped across the reclining chair in her room. *8:13 a.m.: -Seated in her wheelchair in the dining room with chair alarm cord clipped to her collar. […]