Michael J Fitzmaurice South Dakota Veterans Home

In the surveyor’s words

From the most serious findings on record at Michael J Fitzmaurice South Dakota Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF600May 1, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, record review, and interview, the provider failed to protect the resident's right to be free from neglect by one of one licensed practical nurse (LPN) (U) who failed to initiate standing orders for an upset stomach for one of one sampled resident (210) after he became sick in the dining room at supper time and later that night aspirated on his emesis and passed away. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings included: 1. Review of the provider's SD DOH FRI submitted on 2/14/25 at 10:35 a.m. […]

• Actual harm, isolatedF686May 1, 2025

  Based on observation, interview, record review, and policy review, the provider failed to ensure ordered treatments for a current pressure ulcer (skin wound caused by prolonged pressure) were completed and preventative interventions were consistently implemented for one of one sampled resident (47) who developed additional pressure ulcers (wounds) on his toes. Findings include: 1. Observation on 4/29/25 at 11:35 a.m. of resident 47 in his room revealed: *He was seated in a recliner with the footrest halfway up. -He had on a pair of gripper socks on his feet. Observation on 4/30/25 at 1:48 p.m. […]

• No harm, potential for more than minimal, widespreadF880May 1, 2025

  51471 52098 Based on record review, observation, interview, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *Hand hygiene and personal protective equipment (PPE) use by four of four observed staff (E, O, R, and S) for one sampled resident (360) with a physician order for contact precautions related to an infected unhealed chest wound and two sampled residents (10 and 49) on enhanced barrier precautions (EBP) who resided in the NASA unit. *The storage and maintenance of wound care supplies in one of one observed treatment cart located in the NASA unit. Findings include: 1. […]

• No harm, potential for more than minimal, patternF689May 1, 2025

  Based on observation, interview, record review, and policy review, the provider failed to ensure an environment free from potential hazards by not following their policy and ensuring that lighters for two of two sampled residents (33 and 42) who smoked were secured at the nurses' station when not in use. Findings include: 1. Observation on 4/29/25 of resident 33 in the dining room at 4:43 p.m.: *Resident 33 asked homemaker K for cigarettes. *Homemaker K provided her with two cigarettes but no lighter. *Multiple random daily observations from 4/29/25 through 5/1/25 revealed resident 33 was outside of the unit at the designated smoking area. *Observation on 5/1/25 at 2:30 p.m. […]

• No harm, potential for more than minimal, patternF909May 1, 2025

  Based on observation, interview, record review, and policy review, the provider failed to assess bed rails for safe use for five of five sampled residents (24, 28, 41, 44, and 47) who had bed rails on their beds. Findings included: 1. Observation on 4/29/25 at 9:57 a.m. of resident 28's room revealed grab bars were on both sides of the bed. Review of resident 28's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *A device evaluation for his use of bed rails was last completed on 1/13/25. -He utilized the bed rails for turning and repositioning while in bed. There was no documentation that an assessment of the bed rails had been completed to determine safe use or measurements of the bed rails for risk of entrapment and injury. 2. […]