cms_SD: 57

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.

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
57	WESTHILLS VILLAGE HEALTH CARE FACILITY	435033	255 TEXAS ST	RAPID CITY	SD	57701	2017-06-14	241	E	0	1	WA4911	Based on observation, interview, policy review, and quality assurance performance improvement (QAPI) review, the provider failed to: Create a positive and respectful dining experience for 6 of 14 residents (3, 5, 7, 8, 9 and 16) during two of two observed meals in one of two dining rooms (assisted). Ensure staff provided assistance with eating in a dignified manner for two of two randomly observed residents (9 and 15). Ensure one of one randomly sampled resident (17) had not received medication in a public area. Ensure staff answered call lights in a respectable and and followed up in a timely manner. Findings include: 1a. Observation on 6/13/17 from 10:30 am. through 11:25 a.m. of the assisted dining room (ADR) during brunch revealed: Residents 15 and 16 had already received their meals and were being assisted by certified nursing assistant (CNA) B. Resident 9 had been served her meal at 10:30 a.m. and resident 8's meal had been served at 10:45 a.m. At 11:05 a.m. CNA B left the table with residents 15 and 16 and cued resident 9 to eat her meal. She then put a bite of food on the fork and cued resident 8 to eat. She did not sit down with the residents during that time. She went back and while standing helped resident 15 to take another bite of her food. She was the only staff member in the assisted dining room until 11:00 a.m. Three other unidentified CNAs then came into the dining room and assisted residents 3, 5, 7, 8, and 9 with their meal. Resident 8 and 9's meal had not been reheated. Resident 14 had received her meal at 10:55 a.m. and her table mate, resident 7, had not received her food until 11:10 a.m. Surveyor: b. Observation on 6/13/17 from 4:40 p.m. to 5:30 p.m. of the main dining room (MDR) and in the ADR revealed: Five staff consisting of food service and CNAs were available to serve eighteen residents in the MDR. CNA B was the only available staff to serve and assist fourteen residents in the ADR. She tried to serve, assist, cue, and redirect all fourteen residents during the meal. Residents 15 and 18 had been brought to the ADR and sat for approximately fifteen minutes before they were served. Resident 5 sat at a table where resident 13 had been served her food at approximately 4:40 p.m. Resident 5 sat for another twenty-five minutes before he was served. CNA B tried to assist any and all residents in the ADR. But some residents sat with their food in front of them and were unable to eat without assistance. Surveyor: c. Interview on 6/13/17 at 5:15 p.m. with the certified dietary manager and dietary aide A revealed: Typically when a resident came into the dining room they were served. They tried to serve all residents at one table at the same time. It was more difficult in the main dining room to have served all the residents at one table together. Residents could come into the dining room anytime during the hour the meal had been scheduled. Continental breakfast was served from 7:00 a.m. through 9:00 a.m., brunch was served from 10:30 a.m. through 11:30 a.m., and the evening meal was served from 4:30 p.m. through 5:30 p.m. Residents in the assisted dining room were served when a CNA was available to assist them. Even if other residents at the table had to wait to have been served their meals. They had tried to work with nursing staff to not have the CNAs bring the residents into the assisted dining room until they were available to help them. They had worked with the director of nursing on that Works for a bit and then slides back. Surveyor: Interview on 6/14/17 at 9:00 a.m. with the director of health care and the compliance director regarding the staffs' work flow in the assisted dining room revealed: They and the director of nursing (DON) had addressed the work flow issue of residents getting their food before staff were available to assist them with eating in the QAPI minutes for (MONTH) (YEAR) and (MONTH) (YEAR). -Residents were being brought to the assisted dining room and served their food before staff were available to assist them. In (MONTH) (YEAR) they and the DON had performed an audit to ensure residents who needed assistance with eating had not received food items until staff were present to assist them with eating. The facility had not addressed the work flow issue in the (MONTH) (YEAR) QAPI minutes. Staff had felt the work flow in the feeding assistance dining room had improved. There was no QAPI meeting in (MONTH) (YEAR). The (MONTH) (YEAR) QAPI minutes revealed there was still a work flow issue with residents brought to the assisted dining room and served their food before staff were available to assist them with eating. They agreed the work flow issue needed improvement. They did not have a policy, procedure, or audits for the work flow in the assisted dining room. Review of the provider's 1/7/15 Meal Service policy revealed: Residents who could no longer feed themselves would have been provided assistance. Residents that required assistance with dining would have been assisted to that dining room. Staff were assigned to the assist dining room at mealtimes. Review of the provider's undated Meal Service and Distribution policy revealed: A comfortable, attractive atmosphere would be maintained in the dining room area. Food would have been delivered promptly to ensure quality of food for the residents. Nursing service was responsible for assisting at meal time following what was appropriate for residents' needs. Residents' meals were to have been distributed promptly in the dining room by the dietary staff and nursing services. Nursing staff would have been in the dining room during meal service to assist residents with eating and to handle any emergency that might have arisen. 2. Interview on 6/13/17 from 1:00 p.m. through 2:00 p.m. with a group of seven residents revealed they had not liked it when plastic silverware was used during the continental breakfast. The surface of the silverware was smaller and food easily slid off making it harder to eat. 3. Observation and interview on 6/13/17 at 1:15 p.m. during the resident council meeting revealed: Resident 17 was provided medication from unlicensed assistive personnel (UAP) C. He stated he did not like his medication to be given during the meeting. He felt UAP C could have waited or asked him if it was alright to interrupt him. 4a. Interview on 6/13/17 from 1:00 p.m. through 2:00 p.m. with seven residents during a resident council meeting revealed:Call lights were usually answered in a timely manner. The problem was the staff would state to them I'll be right back, OK, or Just a sec. The staff then did not return to assist them. *Four of the residents in the group felt they needed to learn patience due to waiting. b. Interview on 6/14/17 at 10:00 a.m. with resident 12 revealed there were times when he would wait and wait for his call light to be answered. He stated they would come and turn off the light and state they would be right back. Or they would come and say I'll be right there! but not come back until much later. He understood they had other residents to attend to, but it seemed staff took a lot longer to answer his call light in the morning, evening, and during the night. c. Review of the provider's 1/7/15 Call Lights policy revealed: Purpose: To ensure call lights are answered in a reasonable amount of time. The facility goal is an average response time of 10 minutes. Procedure: 1. When the call light is activated, staff members will answer and assist. 2. When staff members are working with another resident and if possible, they will acknowledge the resident and call light, and give the resident an estimated return time. Should the resident need immediate attention, staff will communicate with the charge nurse for assistance. 3. If the call light rolls over to the charge nurse, they will provide follow-up appropriate to the situation. The Director of Nursing or designee will observe and monitor call light usage and response by staff members. Trending and patterns will be reviewed as needed at facility Quality Assurance meetings.	2020-09-01