SD Human Services Center - Geriatric Program

In the surveyor’s words

From the most serious findings on record at SD Human Services Center - Geriatric Program, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 14, 2021

  Based on observation, interview, record review, and policy review, for one (18) of two residents with facility-acquired pressure ulcers the provider failed to:*Ensure the stage two pressure ulcer had not worsened. *Reassess the pressure ulcer treatment to prevent worsening of the ulcer. *Develop/modify a pressure ulcer care plan with interventions to prevent worsening of the ulcer. Findings include: 1. Interview on 7/13/21 at 10:00 a.m. during an initial tour with registered nurse (RN) charge nurse J regarding resident 18 revealed she: *Had a facility-acquired pressure ulcer on her right buttock that had recently worsened. *Had stated: -The ulcer began as a Stage 2 (partial thickness skin loss). -The skin surrounding the open area had now become discolored. […]

• No harm, potential for more than minimal, widespreadF732Jun 5, 2025

  Based on observation, posted staffing review, and interview, the provider failed to ensure the posted nurse staffing information was accessible to residents and visitors at all times and that it included: *The facility's name. *The total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift. 1. Observation on 6/3/25 at 8:00 a.m. revealed the staffing information titled Geriatrics AM Daily Staffing was posted on a central whiteboard near the Spruce 1 unit nurses' station, which was a locked senior care unit. It was not posted in the public area at the front entry of the facility to be accessible to visitors. The unit resident census was posted on a separate sheet of paper on the same whiteboard. 2. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2025

  Based on observation, interview, record review, and policy review the provider failed to follow food safety standards to ensure:*A process was in place to document sanitation levels in sanitation tubs and water temperatures in the wash tubs for three of three kitchenettes.*Refrigerator temperatures that were out of range had documented interventions for one of one refrigerator in one of three kitchenettes according to the provider's policy.*There was a designated hand washing sink in one of three kitchenettes.*Proper food and equipment handling processes were in place for three of three observed mental health aides (L, P, and X) and one of one therapeutic recreation specialist (R).Findings include:1. Observation on 6/2/25 at 4:44 p.m. […]

• No harm, potential for more than minimal, patternF761Jul 14, 2021

  Based on observation, interview, and policy review, the provider failed to ensure: *Three of three medication rooms were kept secured from access of unauthorized and unlicensed staff. *Medication room keys were kept secure. Findings include: 1. Observation on 7/13/21 at 10:00 a.m. on the Spruce 2 resident unit of maintenance supervisor A revealed he opened the medication room with a key. He was showing the life safety surveyor around the building. Surveyor: 2. Interview on 7/14/21 at 2:30 p.m. […]

• No harm, potential for more than minimal, isolatedF609Jun 5, 2025

  Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to follow their policy to file an initial report to the SD DOH within two hours of an incident that involved a sampled resident (41) who had a behavioral event that required her to be placed into a manual hold by staff members according to their policy. Findings include: 1. Review of the provider's 3/25/25 SD DOH FRI regarding resident 41 revealed: *On 3/23/25 at 6:50 p.m., resident 41 was by an exit door in the Spruce 1 unit. -She had placed her belongings in front of that door earlier that afternoon. *Resident 41 walked down the hall to the exit door where her belongings were with a mental health aide. […]