Jenkin's Living Center

In the surveyor’s words

From the most serious findings on record at Jenkin's Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 6, 2023

  Based on interview, record review, South Dakota Department of Health (SD DOH) incident report review, and manufacturer's recommendations review, the provider failed to ensure one of one sampled resident (13) was assessed for the appropriate lift type Maxi Move ( a mechanical device used to transfer residents), the correct size of sling, and the number of staff required to perform a transfer with a Maxi Move lift safely. Findings include: On 10/4/23 at 5:00 p.m. an immediate jeopardy was identified related to quality of care F684. Notice: Notice of immediate jeopardy was given verbally and in writing on 10/4/23 at 7:00 p.m. to administrator A and director of nursing (DON) B and assistant director of nursing (ADON) C. On 10/4/23 at 5:00 p.m. […]

• Actual harm, patternF686Apr 4, 2024

  Based on observation, interview, record review, and policy review, the provider failed to ensure interventions of regular toileting, checking and changing incontinent briefs, or repositioning were consistently implemented for six of six sampled residents (15, 14, 13, 5, 12, and 2) who developed pressure ulcers after their admission to the facility. Finding include: 1. Observation on 3/20/24 at 10:53 a.m. of resident 15 lying in her bed with the head of bed in the upright position. Observation on 3/20/24 at 1:55 p.m. of resident 15 lying in the same position as when she was observed above at 10:53 a.m. that morning. Interview on 3/21/24 at 11:22 a.m. […]

• Actual harm, isolatedF600Apr 4, 2024

  Based on interview, record review, observation, and policy review, the provider failed to ensure one of one sampled resident (1) was free from an injury caused by the use of a mechanical lift sling. Findings include: 1. Interview on 3/21/24 at 8:14 a.m. with resident 1 revealed the following: *She was left in a mechanical lift sling in her bathroom for at least two to three hours. *She stated, I cried, prayed, tried to holler, but no one heard me. I could hear them (staff members) laughing and talking. -The lift sling was pressing into her leg and really hurt, and her leg was still hurting her on the day of the interview. -She thought it was Monday (3/18/24), as the staff members were getting everyone ready for BINGO. […]

• No harm, potential for more than minimal, widespreadF880Jan 30, 2025

  Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for: *The maintenance and disposal of resident care items in one of one shower room. *Transmission based precautions by four of four staff (certified nursing assistant (CNA) T, CNA X, licensed practical nurse (LPN) P, and wound care nurse (WCN) I) for five of five sampled residents (62, 68, 25, 6, and 66) who had care concerns requiring personal protective equipment (PPE). *Hand hygiene and glove use by five of five staff (CNA W, LPN P, LPN DD, LPN N, and staff development coordinator (SDC) H) for four of four observed sampled residents (6, 66, 59, and 328). Findings include: 1. Observation on 1/28/25 from 9:53 a.m. to 10:36 a.m. […]

• No harm, potential for more than minimal, widespreadF812Oct 6, 2023

  Based on observation, record review, interview, and policy review, the provider failed to ensure proper sanitary conditions were followed for 72 of 72 residents who received meals from three of three kitchens; that failure had the potential to affect all 72 residents for foodborne illnesses. Specifically, the provider failed to monitor the temperatures for three of three mechanical dishwashers with incomplete temperature sanitizing logs. Findings include: 1. Observation and interview on [DATE] at 8:06 a.m. with food service supervisor E during the initial tour of the first floor main kitchen revealed: *A mechanical dishwasher that used a high temperature sanitizing process. *The [DATE] dishwasher temperature log that had been posted on the wall across from the dishwasher. […]