Fountain Springs Healthcare

In the surveyor’s words

From the most serious findings on record at Fountain Springs Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 15, 2024

  Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure: *A physician-ordered diet order was followed for one of one sampled resident (1). *Appropriate and timely emergency medical intervention was initiated for one of one sampled resident (1) who choked during a meal service. On [DATE] at 9:00 a.m., an Immediate Jeopardy was identified for a FRI related to the quality of resident care and treatment that occurred on [DATE]. The investigation revealed verbal and written education initiated on [DATE] removed the immediacy. […]

• Actual harm, isolatedF689Jan 2, 2024

  Based on observation, interview, record review, review of the facility-reported incident (FRI), and policy review, the provider failed to maintain a secured environment for one of one sampled resident (1) with a history of wandering and severe cognitive impairment who had eloped on 12/25/23 outdoors and into a fenced courtyard approximately 100-150 feet from the door he had exited from. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE] and currently resided at the facility. *His diagnoses included Alzheimer's dementia, psychosis, and a history of prostate cancer. […]

• No harm, potential for more than minimal, widespreadF838Jan 6, 2022

  Based on observation, interview, and facility assessment review, the provider failed to ensure a facility-wide assessment had: *Been updated annually. *Included -A comprehensive review of the current resident population. -Resources needed to care for the residents. -Staffing requirements. -Services provided. -Equipment, supply inventories, maintenance, and activity logs. -Health information managing and sharing. -Facility and community based risk assessment, utilizing an all-hazards based approach. Findings included: Review of the provider's undated facility assessment revealed: *The assessment was twenty-two pages long. *It had included an overview of the provider's population from 11/13/18 through 11/12/19. […]

• No harm, potential for more than minimal, widespreadF880Jan 6, 2022

  Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were maintained for: *Appropriate personal protective equipment (PPE) use by one of one certified nurse aide (CNA) (H) between transitions of care for three of three residents (51, 130, and 277). *Availability of disinfectant supplies in one of two observed PPE carts outside of two of two residents' rooms who were on droplet precautions. *Handling of wound care supplies by one of one licensed practical nurse (LPN) G during one of one observed resident's (127) wound care treatment. *Appropriate use of PPE or other communication alernative(s) by staff when communicating with one of one resident (25) with a hearing impairment. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF886Jan 6, 2022

  Based on observation, interview, review of COVID-19 testing competency reviews, review of the Abbott BinaxNOW COVID-19 Ag ([MEDICATION(S)]) product insert instructions, and policy review, the provider failed to ensure: *One of one registered nurse (RN)/unit coordinator (F) had conducted COVID-19 testing in a manner consistent with their policy and according to manufacturer's recommendations. *One of one RN/unit coordinator (F) and one of one director of nursing (DON) (C) had completed a BinaxNOW COVID-19 testing competency prior to administering COVID-19 testing. Findings include: 1. Observation and interview on 1/4/22 at 10:24 a.m. […]