cms_SD: 24

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

This data as json, copyable

rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
24	AVANTARA HURON	435020	1345 MICHIGAN AVENUE SW	HURON	SD	57350	2019-05-09	679	E	0	1	L4FS11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to ensure four of seven sampled residents (24, 52, 61, and 76) had individualized and meaningful activities. Findings include: 1. Review of resident 52's medical record revealed: She was admitted on [DATE]. Her [DIAGNOSES REDACTED].>-Age related [MEDICAL CONDITION]. -Vitamin D deficiency, unspecified. -Heart failure. Review of resident 52's 3/20/19 Minimum Data Set (MDS) assessment revealed: Her Brief Interview for Mental Status (BIMS) assessment score was three indicating her cognition was severely impaired. It was very important for her to: -Have books, newspapers, and magazines to read. -Be around animals such as pets. -Keep up with the news. -Go outside and get fresh air. -Participate in religious services. It was somewhat important for her to: -Listen to music. -Do things with groups of people. -Do her favorite activities. Review of resident 52's current undated care plan revealed her interventions for activities were: Inform of daily activities and assist with wheelchair to and from activities of choice. Activity group interests: games (BINGO), crafts, parties, religious activities Methodist. Leisure activity interests: TV, visiting, phone, watching/listening to sports. Observation on 5/7/19 at 3:00 p.m. and again at 4:02 p.m. of resident 52 revealed: She was sitting in her recliner in her room and was awake. -There was no television in her room, and there was no music playing. At 3:00 p.m. there was a puzzle activity going on in the Independence dining room. At 4:00 p.m. they were gathering residents for another activity in the Independence dining room, but she had not been invited. She had not participated in either of those activities. Interview on 5/7/19 at 4:25 p.m. with resident 52 in her room revealed: The activity staff person did not come in to ask her to join the activity. There had been no TV in her room, and there was no music on. She stated she liked to watch TV. She used to have a TV, but was not sure where it had gone. Observation on 5/7/19 at 5:43 p.m. of resident 52 revealed she was still sitting in recliner in her room and was awake. Observation on 5/8/19 from 7:51 a.m. through 10:41 a.m. of resident 52 revealed: She was in her room sitting up in her wheelchair. -Her head was hanging down, and her eyes were closed. At 7:55 a.m. she was taken into the dining room for breakfast. At 9:43 a.m. she was in her room sitting in her chair with the newspaper on her lap. -Her head was hanging down, and her eyes were closed. At 10:41 a.m. she was still sitting in her chair in her room with her eyes closed. Interview on 5/8/19 at 2:54 p.m. with social services assistant/activity assistant P revealed: Her primary responsibility was completing one-to-one activities with the residents. It could be anything but usually she visited with the residents. Observation on 5/8/19 at 3:47 p.m. of resident 52 revealed: She was laying in bed sleeping. At that time they had a gentleman singing in the Independence dining room. Review of resident 52's activity documentation revealed: In (MONTH) 2019: She had four out of eighteen days documented for activities. In (MONTH) 2019: She had seven out of thirty days marked for activities. In (MONTH) 2019: She had two out of six days marked for activities. Interview on 5/9/19 at 8:21 a.m. with the activity director regarding resident 52 revealed: She was supposed to have one-to-one programming three times per week. She personally did not ask her to attend yesterdays activity. She was not aware the resident liked to watch TV. The social services assistant/activity assistant P provided the one-to-one activities. -She was unavailable to interview that morning. She could participate in group activities, but staff would have to ask her to join. They were not asking her regularly. Interview on 5/9/19 at 8:41 a.m. with the social services director revealed: Resident 52 had come into the facility on Medicare. The Medicare rooms had TVs in them. She had to move out of that room when she was no longer on Medicare. The room they moved her into did not have a TV, and the resident or family would have to provide their own. They were unsure if the family was going to provide one or not. There were other areas in the building she could have watched TV, but they had not taken her there. 2. Review of resident 76's medical record revealed: He was admitted on [DATE]. His [DIAGNOSES REDACTED].>-Unspecified dementia without behavioral disturbance. -[MEDICAL CONDITION]. -Malignant neoplasm of prostrate. -Other retention of urine. Review of resident 76's 1/16/19 MDS revealed: He had long and short term memory problems. The staff interview had been completed for his preferences that included: -Listening to music. -Being around animals such as pets. -Doing things with groups of people. -Participating in favorite activities. -Participating in religious activities. Review of resident 76's current undated care plan revealed his interventions for activities were: Inform of daily activities assist with wheelchair assist with directions assist with transfers. Activity group interests: Bingo, parties, religious activities Catholic activities. Leisure activity interests: Reading group, TV, visiting, radio. Review of resident 76's activity documentation revealed: In (MONTH) 2019: He had nine out of thirty-one days documented for activities. In (MONTH) 2019: He had twelve out of thirty days documented for activities In (MONTH) 2019: He had three out of six days documented for activities. Observation on 5/7/19 at 3:00 p.m. and again at 4:10 p.m. with resident 76 revealed he was laying in bed with his eyes closed. There was no music or TV on in his room. At 4:17 p.m. the reading activity had started in the Independence dining room, but he had not been taken to it. Observation on 5/8/19 at 9:45 a.m. and again at 10:41 a.m. of resident 76 revealed he was sitting in his chair in his room. He was sleeping. Interview on 5/9/19 at 8:31 a.m. with the activities director regarding resident 76 revealed staff were to assist him to activities. He should have been invited to the reading activity. 3. Review of Resident 61's medical record revealed: She was admitted on [DATE]. Her [DIAGNOSES REDACTED].>-Unspecified dementia without behavioral disturbances. -Age related [MEDICAL CONDITION] without (w/o) current pathological fracture. -Hypertension. -Vitamin D deficiency. Review of resident 61's 4/2/19 MDS assessment revealed: There was no BIMS assessment score due to significant cognitive impairment. Resident representative was not available for an interview for her daily activity preferences, and the resident was not able to be interviewed. She was totally dependent upon two staff for assistance with bed mobility, transfers, toilet use, and bathing. She was totally dependent upon one staff person for assistance with locomotion on and off the unit. She required the extensive assistance of two staff for dressing and personal hygiene. She required the extensive assistance of one staff person for eating. Observations of resident 61 on 5/7/19 at the following times revealed: At 8:40 a.m. she was in her wheelchair in her room with her son. -She had no TV or radio in her room. From 9:37 a.m. until 10:06 a.m. she was in her wheelchair in the hallway sitting next to the wall. From 3:00 p.m. through 4:25 p.m. she was resting in her room in bed with the light off. -There was a reading activity going on in the dining room at 4:00 p.m. Review of resident 61's activity logs from 3/26/19 to 5/6/19 revealed: There were forty-four days with opportunities for activities. There had been twenty-one days she had no activities provided to her. She had attended seventeen reading groups. She had attended five religious activities. She had been provided with seven one-to-one activities. Review of the provider's (MONTH) 2019 and (MONTH) 2019 activity calendars revealed: Between (MONTH) 1, 2019 and (MONTH) 8, 2019: -Reading group was offered twenty-eight times. -There were forty-five religious activities offered. Review of resident 61's 5/8/19 care plan revealed: She had altered participation in activities due to cognitive impairment. She was to passively participate in group activities one to two times per week. -Her group activity interests included music, parties, religious activities, and communion. She was to have leisure activities daily. -Her leisure activity interests included reading group and visiting with family. Interview on 5/9/19 at 10:28 a.m. with CNA/activities coordinator C regarding resident 61 revealed: They had recently had eighteen admissions from another facility, and she was still getting to know those residents. She was providing the resident with one-to-one activities three times per week. She indicated the resident spent a lot of time in bed resting. She indicated the resident would attend reading group when it was offered. She stated she needed to look at the way activities were implemented on [NAME] wing. 4. Review of resident 24's 2/26/19 MDS assessment revealed: She had a short-term memory deficit. Verbally and non-verbally she was rarely/never understood. Sometimes understood, and responded adequately to simple, direct communication only. She was totally dependent on staff assistance for bed mobility, transferring, locomotion on the unit, dressing, eating, using the bathroom, and personal hygiene. Interview on 5/9/19 at 10:12 a.m. with CNA C regarding resident 24 revealed: They tracked their one-to-one activities. They did not keep track of the amount of time they spent with the residents on their one-to-one activities. She stated that there was no way to tell how long they had spent with each resident with their current documentation. Review of resident 24's 10/31/17 care plan revealed an intervention for one-to-one visits three times a week. 5. Interview on 5/08/19 at 9:04 a.m. with social services assistant P revealed: She completed all one-to-one activities. She would document the activities into the activities detail report in the computer. There were no entries of the amount of time spent with resident's for one-to-one activities. She was unaware she needed to document the amount of time she was spending with each resident. Interview on 05/09/19 at 8:29 a.m. with the DON revealed she could not say how long the one-to-one activities lasted by reviewing their current documentation. Review of the 11/14/17 Individual Activities and Room Visit Program policy revealed: A room visit was seven to fifteen minutes in length. It was the responsibility of the facility and the activity staff to make regular contacts and offer supplies as needed. Review of the provider's 11/14/17 Activity Program policy revealed: Activity programs designed to meet the needs of each resident were available on a daily basis. Activities would encourage the maximum individual participation and be geared toward individual resident needs. Activities would be scheduled seven days per week. Individualized group activities were provided that reflected schedules, choices and rights of residents.	2020-09-01