Every finding on record at Avera at Home

Based on observation, interview, and policy review, the provider failed to ensure that opened or expired patient care supplies were not available and ready for patient use in one of one central supply room.Findings include: --- 1. Observation on 5/20/26 at 10:50 a.m. inside the central supply room revealed there were multiple shelving units on which individual plastic storage bins sat. Those bins held various types of medical supplies for patients' use. Inside one bin on the top shelf of cart F, there were single-use plastic medication syringes inside sealed plastic bags. There were also loose, unpackaged syringes that lay beneath, among, and on top of those sealed bags. Inside another bin, there were individually packaged adult-sized tracheostomy masks (a medical device that fits over a tracheostomy site). One package was torn open, exposing that mask. Inside a third bin, there were individually packaged "Oxymasks" (oxygen masks) with attached tubing. One package was torn open, exposing the mask and tubing.  Inside one of the storage bins on the second shelf of cart F, there were more individually packaged oxygen masks. One package was torn open, exposing the mask. Inside another bin, there were individually packaged one-way valves with filters (a piece of medical equipment used with a rescue breathing mask). One package was torn open, exposing the valve. Inside a third bin, there were individually packaged "Air Entrainment Masks" (a type of oxygen therapy mask). One package was torn open, exposing the mask. On the shelving unit between cart A and cart E, there were six canisters of bleach wipes. The expiration date on one canister was December 2025. Two other canisters had expiration dates of March 2026.2. Observation and interview on 5/20/26 at 11:30 a.m. with care assistant (CA) D at the south nurses' station revealed there was a canister of bleach wipes on the counter of that nurses' station. The expiration date on the bleach wipe canister was August 2025. CA D used the bleach wipes to disinfect items such as patients' shower chairs and wheelchairs. She did not know that the bleach wipes she was using were expired. She acknowledged that the expired canister should have been discarded.3. Interview on 5/20/26 at 1:40 p.m. with registered nurse (RN) F regarding management of the patients' medical supplies in the central supply room revealed that support specialists B and G were responsible for maintaining the central supply room which included discarding damaged or expired medical supplies. RN F stated that the individually packaged patient care supplies, like oxygen masks, were single-use items. If those packaged supplies were opened and not used, they were expected to be discarded. 4. Interview on 5/20/26 at 1:45 p.m. with support specialist B revealed that she and support specialist G ordered and stocked the patient care supplies in the central supply room. It was the responsibility of "anybody really [who used the central supply room]" to ensure that expired or damaged patient care supplies were removed and discarded from that room. She stated, "We keep on top of that really well."5. Observation and interview on 5/20/26 at 4:35 p.m. with manager A in the central supply room revealed she acknowledged the above findings. She stated that opened, unused patient supplies were not free from contaminants and should be removed and discarded from the central supply room. It was the responsibility of the staff person who opened that unused package to discard it. It was the responsibility of every staff person who used the central supply room to ensure that expired patient care supplies were discarded and not available for patient use.6. A Central Supply Room Storage policy (including the provider's procedure for removing expired and damaged patient medical supplies) was requested from manager A on 5/20/26 at 4:10 p.m. On 5/25/26 at 10:50 a.m., manager A indicated there was no Central Supply Room Storage policy.

Based on observation and interview, the facility failed to protect medical gas storage as required. The required one-hour fire separation was not maintained in the storage room. Findings include: 1. Observation on 6/13/23 at 11:00 a.m. revealed the wall behind the two liquid oxygen dewars was significantly damaged. The gouges in the wall would not maintain a one-hour barrier as required. The maintenance director acknowledged the one-hour fire separation had not been maintained at the time of observation. The deficiency affected one of four smoke compartments.