Avantara Arrowhead
Inspection history, citations, penalties and survey trends for this long-term care facility in Rapid City, South Dakota.
- Location
- 2500 Arrowhead Dr, Rapid City, South Dakota 57702
- CMS Provider Number
- 435051
- Inspections on file
- 25
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Avantara Arrowhead during CMS and state inspections, most recent first.
Two RNs failed to report allegations of suspected abuse after two residents with cognitive impairment reported being handled roughly by agency CNAs, resulting in pain and minor injuries. The nurses either addressed the issue directly with the CNA or documented it in progress notes but did not escalate the allegations to management as required.
A deficiency was identified when a CNA failed to provide care in pairs as required for a resident with cognitive and psychosocial needs, and another CNA did not use the required mechanical lift for a resident with severe cognitive impairment, resulting in a fall. Both incidents involved staff not following clearly documented care plans and care sheets.
A resident with a recent neck fracture and chronic pain did not receive timely or adequate pain management due to delays in medication delivery, staff communication issues, and inconsistent responses to pain complaints. The resident experienced significant discomfort, reported long wait times for assistance, and ultimately left the facility against medical advice after expressing dissatisfaction with care.
Three residents experienced falls due to staff not following safety protocols for equipment use, including failure to secure safety belts and lock wheels on bath chairs and mechanical lifts. In one case, a resident suffered cervical fractures after falling from an unsecured bath chair, and staff did not complete required neurological assessments. Other incidents involved residents falling during transfers when safety straps were not used, despite staff being aware of these requirements. Care plans were not updated after these events, and facility policies for safe equipment operation were not consistently followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
The facility did not ensure that a resident received proper care for existing pressure ulcers and failed to implement adequate preventive measures to stop new ulcers from developing.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
Multiple residents using oxygen and CPAP equipment did not have their respiratory devices cleaned, replaced, or stored according to facility policy and manufacturer instructions. Observations showed dusty concentrators, undated and improperly stored nasal cannulas, and missing documentation for scheduled cleaning and replacement. Staff interviews revealed confusion about responsibilities, and facility records confirmed inconsistent scheduling and documentation of required maintenance tasks.
An LPN administered an incorrect dose of diclofenac sodium gel by failing to use the manufacturer's dosing card and also crushed and administered a delayed-release omeprazole tablet to a resident, despite facility policy and manufacturer instructions prohibiting this. These actions resulted in a medication error rate of 6.9%.
Surveyors found that kitchen staff did not follow proper hand hygiene procedures, specifically failing to use a paper towel to turn off the faucet after washing hands, as required by facility policy. The kitchen and food storage areas were not maintained in a clean condition, with dust and buildup observed on equipment and surfaces. Additionally, food items in the dining room refrigerator were improperly labeled and stored, with some items undated, spoiled, or moldy, and not discarded as required by policy.
Staff did not consistently follow infection control protocols, including failure to wear required PPE when entering rooms under Enhanced Droplet Precautions, inadequate hand hygiene practices after glove removal and before resident care, and improper cleaning and disinfection of a shared glucometer used for multiple residents. Facility policy requiring individual, labeled glucometers for each resident was not followed, and staff did not have necessary cleaning supplies readily available.
A resident's advance directive wishes were not accurately identified or documented after returning from a hospital stay, resulting in conflicting code status information between the EMR and paper chart. The EMR was updated to 'Intubate Only' without discussion with the resident, despite signed DNR documents and a care plan indicating DNR status. Staff confirmed they would follow the highest level of care listed, which did not reflect the resident's wishes.
An LPN left a resident's EMR information visible and unsecured on a medication cart computer while away administering medications, allowing staff and residents to pass by and view the protected health information. The DON confirmed that the system has a lock screen feature and staff are expected to use it, in accordance with the facility's HIPAA policy.
A resident with multiple mental health diagnoses, including PTSD, was admitted with an inaccurate Level 1 PASRR that failed to identify their mental illness, resulting in the lack of evaluation for specialized mental health care needs. The resident did not receive services for PTSD, and facility staff acknowledged the PASRR was completed incorrectly.
Two residents with intact cognition and complex psychiatric histories, including PTSD and depression, did not have their care plans reviewed or revised to address trauma exposure and related needs. Their care plans lacked individualized interventions for trauma triggers, coping mechanisms, and specific behavioral symptoms, despite facility policy requiring person-centered care planning. Staff interviews confirmed reliance on care plans for guidance, but trauma-informed care was not addressed for these residents.
Two residents with PTSD and histories of trauma did not receive individualized, trauma-informed care planning or interventions. Their care plans lacked specific strategies to address their mental health needs, triggers, or behaviors, and trauma assessments were incomplete or inaccurate. Staff confirmed that trauma-informed care was not incorporated as required by facility policy.
A resident did not receive the medically-related social services needed to help achieve the highest possible quality of life, as required by regulations.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A CNA handled a resident roughly during morning care, resulting in injuries and pain, while another resident with cognitive impairment made unsolicited sexual contact with a female resident after missing scheduled Depo-Provera injections. Both incidents involved failures to protect residents from abuse, as identified through staff observations, resident reports, and record reviews.
Two residents experienced significant medication errors when staff failed to administer physician-ordered medications due to missing or unavailable doses, despite some medications being present in the E-Kit. Staff did not consistently check all available sources for medications, and the facility did not complete required medication error reports for all missed doses, as confirmed by the DON. The medication reordering and communication processes were not reliably followed, leading to repeated missed doses and incomplete documentation.
A resident with multiple complex medical conditions did not receive several scheduled Depo-Provera injections due to medication unavailability, and there was no documentation that the physician was notified of these missed doses as required by facility policy. The DON confirmed the lack of physician notification for the missed doses, and medication error reports were not completed for all instances.
Two CNAs failed to provide timely incontinence care to two residents with continence assistance needs, resulting in both individuals remaining in soiled briefs until the night shift. One resident, with paraplegia and other medical conditions, was left unattended after multiple requests for help, while another, with moderate cognitive impairment and ataxic cerebral palsy, was found soaked in urine. These actions were confirmed through staff interviews and record review, and the incidents were reported as neglect.
A resident with severe cognitive impairment and multiple health conditions developed a skin rash with scabbing and abrasions, but did not receive scheduled bathing for extended periods and experienced delays in receiving physician-ordered topical treatment. Staff interviews revealed uncertainty about the bathing schedule and documentation lapses, while medical records showed delayed initiation of appropriate skin care interventions.
A resident with significant medical comorbidities and high risk for pressure ulcers developed a new skin injury that was observed by a CNA and reported to nursing staff. However, the responsible RN did not assess or document the injury, notify the physician, or initiate treatment, and subsequent staff also failed to follow proper procedures for assessment and care. This resulted in delayed intervention and a failure to follow the facility's protocol for new skin injuries.
A CNA observed a new skin injury on a resident and reported it to the RN and wound care nurse. The RN did not assess or document the injury, nor notify the physician or obtain treatment orders. The CNA, acting outside their scope of practice, independently applied a dressing to the injury without direction from the RN.
A resident with multiple comorbidities and a full code status was found unresponsive and cold by staff. The RN and LPN did not assess for irreversible signs of death or promptly initiate CPR, and there was a delay in identifying the resident's code status and calling 911. Documentation of the resident's change in condition was also lacking, resulting in a deficiency related to failure to provide basic life support as required.
A resident with moderate cognitive impairment and a history of wandering and falls was allowed outside without required supervision, contrary to their care plan. The resident fell while unsupervised, resulting in injuries and a trip to the ED. Staff interviews confirmed that supervision was necessary, but it was not provided at the time of the incident.
A resident with multiple health conditions suffered a skin tear on her leg, which continued to bleed over several days. Despite repeated dressing changes by staff, the facility lacked adequate supplies, and the decision was made not to send the resident to the emergency department. The resident's condition worsened, and she passed away shortly after. The facility's neglect and wound care policies were not effectively followed, leading to inadequate care.
A resident at high risk for pressure injuries was admitted with only heel lift boots as an intervention. Despite a care plan requiring repositioning every two hours, this was not consistently done, leading to a pressure injury. Staff interviews revealed communication and documentation gaps, and weekly skin assessments were not completed as required.
The provider failed to monitor a bowel management program for a resident with ataxic cerebral palsy who experienced significant weight loss and frequent diarrhea. Despite the resident's reports and documentation of multiple loose stools, the physician and dietitian were not notified, and the resident continued to receive laxatives and stool softeners. Staff interviews revealed a lack of communication and awareness regarding the resident's condition, contributing to the deficiency.
The facility failed to ensure proper medication administration and documentation. An RN left nutritional supplements and Mirilax on a table without ensuring consumption, leading to inaccurate MAR documentation. An LPN administered lorazepam and morphine but did not document it. Additionally, tube feeding and water flushes for a resident with a feeding tube were not accurately documented.
The provider failed to ensure medications were administered as ordered for two residents. One resident received incorrect doses of clonazepam on multiple occasions, and another resident was given lisinopril without the required blood pressure check. These errors were not reported or investigated as per facility policy.
The provider failed to ensure accurate labeling of prescription medications for two residents and allowed a CMA to alter a medication label. Resident 14's MAR indicated a daily dose of clonazepam, but the blister pack label stated 'as needed,' which the CMA altered with a marker. For Resident 32, the RN administered lisinopril without following the hold instruction on the blister pack label, which was not present on the MAR. The DON confirmed that staff should reconcile discrepancies before administering medications.
The provider failed to ensure proper infection control practices by an OT and an ADON. The OT did not perform hand hygiene or change gloves after assisting a resident, and the ADON improperly handled the faucet during hand washing. Both staff members confirmed their lapses in following infection control protocols.
Failure to Timely Report Allegations of Suspected Abuse by Nursing Staff
Penalty
Summary
Two registered nurses failed to report allegations of suspected abuse involving two residents. In the first case, a resident with Parkinson's disease, spinal stenosis, and moderate cognitive impairment reported to a nurse that an agency CNA had handled him roughly during care, resulting in pain and minor injuries. The nurse spoke to the CNA and instructed her to be more careful but did not report the allegation to management as required. The resident had visible bruising and scabbing, some of which was attributed to the use of a sit/stand lift and scratching due to dry skin. In the second case, another resident with Alzheimer's disease, dementia, and moderate cognitive impairment told an agency CNA that she was being rough during incontinent care, causing pain due to arthritis in her shoulders. The CNA slowed down after being told, but did not offer pain medication or inquire further. The CNA reported the resident's statement to a nurse, who checked on the resident later and documented the incident in the progress notes but did not recognize it as an allegation of abuse requiring immediate reporting to management. Both incidents were later discovered by facility management during reviews of resident complaints and progress notes. The failure to report these allegations of suspected abuse by the nurses constituted non-compliance with regulatory requirements for timely reporting and investigation of abuse allegations.
Failure to Follow Care Plans for Supervision and Transfer Leading to Deficiencies
Penalty
Summary
A deficiency occurred when an agency CNA failed to follow a resident's care plan requiring 'cares in pairs' for a resident with ataxic cerebral palsy, delusional disorder, major depressive disorder, and epilepsy. The resident, who was cognitively intact, had a care plan and care sheet indicating that two staff members were required to be present during care due to a history of embellishing or fabricating stories. Despite this, the agency CNA provided care alone, which led to an allegation of inappropriate touching. The resident's care plan was clearly marked, and the CNA had received training on the 'cares in pairs' procedure prior to the incident. Another deficiency was identified when a CNA did not follow the care plan for a resident with traumatic subarachnoid hemorrhage, insomnia, dysphagia, depression, hypertension, and repeated falls. The resident, who was severely cognitively impaired, required a total body mechanical lift with two staff members for all transfers, as documented in both the care plan and care sheet. The CNA transferred the resident using a gait belt instead, resulting in a fall. The CNA had previously sought clarification from therapy staff but misunderstood the instructions, and the care plan had not changed. Both incidents involved staff not adhering to the individualized care plans and care sheets, which were clearly documented and communicated. In both cases, the staff involved had current certifications, completed required trainings, and had no background check concerns. The deficiencies were identified through interviews, record reviews, and facility-reported incidents.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with a recent C2 vertebra fracture, chronic pain syndrome, depression, anxiety disorder, and insomnia was admitted to the facility and consistently reported unmanaged pain and lack of staff response to requests for pain medication. The resident experienced long call light wait times and voiced concerns that staff, particularly an LPN, were not assisting with her needs. Documentation shows that the resident was in significant pain, as evidenced by pain scores of 10, and was heard yelling in discomfort when repositioned. The resident did not receive her prescribed acetaminophen on the first day and had to wait for narcotic pain medication due to delays in prescription processing and pharmacy communication issues. Staff interactions with the resident were marked by escalating behaviors and verbal altercations. The LPN instructed CNAs to provide care in pairs due to the resident's behaviors and eventually advised staff to avoid the resident for their own safety, following continued threats and verbal abuse from the resident. The LPN was later suspended for inaccurate and subjective charting and for instructing staff to stop providing care to the resident. During this period, the resident continued to express pain and dissatisfaction with the care provided, ultimately deciding to leave the facility against medical advice. The facility's medication administration records confirmed that the resident did not receive all prescribed pain medications in a timely manner. Delays were attributed to prescription errors and issues with the medication dispensing system. Interviews with staff and review of progress notes indicated that the resident's pain was not adequately managed during her short stay, and staff responses to her needs were inconsistent and, at times, insufficient.
Failure to Prevent Accidents Due to Improper Equipment Use and Inadequate Supervision
Penalty
Summary
Staff failed to ensure the safety of three residents who experienced falls related to improper use of equipment. In one instance, a certified nurse aide (CNA) did not secure a safety belt on a bath chair while a resident was seated, resulting in the resident falling forward onto the floor after being moved out of the whirlpool bathtub. The resident sustained a head laceration, nosebleed, and was later found to have cervical fractures. The CNA involved had previously signed an education sheet confirming receipt of training on proper equipment use, including securing safety belts, just three days prior to the incident. However, the CNA stated she was unaware of the requirement to use the seat belt. Following the fall, there were discrepancies in the accounts provided by the registered nurses (RNs) who responded to the incident, and it was unclear whether the resident was appropriately repositioned. The resident was moved with a Hoyer lift to a wheelchair before emergency medical services arrived, despite facility policy indicating that residents with suspected major injuries should not be moved. Additionally, there was no documented neurological evaluation completed after the fall, contrary to facility policy requiring such assessments for falls involving head trauma. In two other incidents, staff failed to use required safety straps during transfers with mechanical lifts. One resident fell from a sit-to-stand lift when the leg straps were not used, resulting in pain and hospital evaluation. Another resident fell from a bath chair after the seatbelt was removed and not replaced, and the chair's wheels were not locked. In both cases, staff were aware of the safety requirements but did not follow them. Care plans were not updated following these incidents as expected. Facility policies and manufacturer instructions required the use of safety belts and locking of wheels during equipment use, but these were not consistently followed.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Failure to Clean and Store Respiratory Equipment per Policy
Penalty
Summary
The facility failed to ensure that respiratory treatment equipment, including oxygen concentrators, nasal cannulas, and CPAP machines, was cleaned and stored according to manufacturer instructions and facility policy for multiple residents. Observations revealed that several oxygen concentrators had visible dust and debris on their filters and exteriors, with one concentrator labeled with another person's name. Nasal cannulas were found undated, improperly stored—such as hanging over wheelchair wheels or lying on the floor—and in some cases, not replaced according to the facility's weekly schedule. Documentation in the treatment administration records (TAR) was inconsistent or missing for scheduled cleaning and replacement tasks. Residents using oxygen and CPAP equipment had varying degrees of cognitive function and medical needs, including chronic respiratory failure, hypoxia, and sleep apnea. Interviews with residents indicated a lack of awareness regarding the maintenance of their respiratory equipment. For example, one resident with severe cognitive impairment could not confirm if his CPAP mask and tubing or oxygen concentrator were cleaned, while another resident with intact cognition was unaware of any replacement or cleaning of her equipment. The CPAP mask and tubing for one resident were left assembled and not cleaned or scheduled for cleaning as required. Staff interviews revealed confusion and inconsistency regarding responsibilities for cleaning and maintaining respiratory equipment. Certified medication aides and LPNs provided differing accounts of who was responsible for cleaning concentrator filters, with some believing it was a nursing duty and others attributing it to maintenance or an outside oxygen company. The infection preventionist and DON confirmed that cleaning and replacement tasks were to be documented in the TAR, but acknowledged that documentation was missing or not scheduled for some residents. Facility policies required weekly cleaning and replacement of equipment, proper storage of nasal cannulas, and documentation of these tasks, but these procedures were not consistently followed.
Medication Error Rate Exceeds 5% Due to Improper Administration and Crushing of Medications
Penalty
Summary
A medication error rate of 6.9% was identified during observation of medication administration by an LPN. The LPN dispensed an unknown amount of diclofenac sodium 1% gel for a resident's arthritis pain and inflammation, failing to use the manufacturer's enclosed dosing card as required. The LPN was unaware of the measuring device included in the medication packaging and could not confirm the correct dose, resulting in improper administration. The medication administration record (MAR) specified a two-gram dose, but the LPN guessed the amount and only discovered the dosing card after the error was pointed out. Additionally, the same LPN crushed and administered an extended-release medication, omeprazole 20mg delayed-release oral tablet, to another resident who required medications to be crushed. The MAR did not indicate that these medications should be crushed, and the LPN was unaware that omeprazole was a delayed-release formulation, only realizing the error after reviewing the medication label. The facility's policy and the manufacturer's recommendations both specify that extended-release or delayed-release medications should not be crushed and that medications must be administered as prescribed and in accordance with manufacturer specifications.
Failure to Follow Food Safety and Hand Hygiene Protocols
Penalty
Summary
Surveyors observed multiple failures to follow standard food safety and hand hygiene practices in the facility's kitchen and dining areas. Three of five kitchen staff, including a cook and two dietary aides, did not use a paper towel to turn off the faucet after handwashing, contrary to posted instructions and facility policy. This improper handwashing technique was observed during six of nine handwashing events. The dietary manager and infection preventionist confirmed that the policy requires using a paper towel to turn off the faucet to prevent recontamination. Additionally, the kitchen environment was not maintained in a clean condition, with a dusty power cord hanging above clean dishware, uncovered serving utensils, and dust and buildup on ventilation filters and air vents near food preparation and dishwashing areas. In the dining room refrigerator, food items belonging to three residents were found improperly stored. Several containers were labeled with resident names but lacked dates, and one container emitted a foul odor when opened. Another bag of vegetables was visibly moldy and undated. The activities director, responsible for managing the refrigerator, acknowledged that food without dates should have been discarded during the last cleaning, as per facility policy, which requires all food brought in from outside to be labeled with the date and discarded after three to five days. The cleaning log indicated the refrigerator had not been deep cleaned since the previous week, and undated or expired food was not removed as required.
Infection Control Failures in PPE Use, Hand Hygiene, and Glucometer Disinfection
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several observed instances. A guest services aide entered two residents' rooms, both under Enhanced Droplet Precautions, without donning the required personal protective equipment (PPE) such as gown, gloves, and eye protection, as indicated by signage. The aide only wore a face mask and did not change it between rooms, although she performed hand hygiene upon exiting each room. The aide acknowledged that PPE was expected in these rooms. A certified nurse aide (CNA) was observed removing unclean gloves after providing personal care to a resident and then immediately putting on a new pair of gloves without performing hand hygiene in between. The CNA confirmed that hand hygiene should have been performed after glove removal and before donning new gloves. Additionally, an LPN was seen placing a straw into a resident's water cup with bare, unwashed hands, and admitted that she should have either washed her hands or worn gloves before handling the straw. There was also a failure to follow manufacturer and facility policy regarding the cleaning and disinfection of a shared blood glucose monitor (glucometer). An LPN used an unlabeled glucometer for multiple residents, did not have cleaning wipes readily available, and did not follow the manufacturer's instructions for cleaning and disinfecting the device between uses. The facility's policy required individual glucometers for each resident, properly labeled and stored, but this was not followed, as confirmed by the Director of Nursing.
Failure to Accurately Document and Confirm Advance Directive After Hospitalization
Penalty
Summary
A deficiency occurred when a resident's advance directive wishes were not accurately identified and documented after returning from a hospital stay. The resident's electronic medical record (EMR) listed his code status as 'Intubate Only,' while two signed Do Not Resuscitate (DNR) documents were present in both his EMR and paper chart, each signed by the resident, a provider, and a facility agent. The resident's care plan also indicated DNR status, and during an interview, the resident confirmed he believed his code status was DNR and expressed that he did not want to be intubated again after a previous experience. A licensed practical nurse (LPN) confirmed the discrepancy between the paper chart (DNR) and the EMR (Intubate Only), stating she would follow the highest level of care listed, which was 'Intubate Only.' The nurse supervisor updated the EMR to 'Intubate Only' after the resident returned from the hospital, based on a change observed during the hospital stay, but did not discuss this change with the resident. The director of nursing (DON) stated that any code status change after hospitalization should be confirmed with the resident, and that code status is reviewed at care conferences. The failure to confirm and accurately document the resident's code status led to the deficiency.
Failure to Secure Resident PHI on Unattended EMR Screen
Penalty
Summary
A licensed practical nurse (LPN) failed to secure a resident's protected health information (PHI) by leaving the electronic medical record (EMR) screen unlocked and visible on the medication cart while administering medications in the west hall. During this time, multiple staff members and residents walked past the unlocked screen, which displayed the resident's EMR information. The LPN acknowledged that the computer screen should have been locked when unattended. The director of nursing (DON) confirmed that the facility's EMR system includes a lock screen feature and that staff are expected to use it whenever they step away from the computer. Review of the facility's HIPAA policy further emphasized the requirement to log off computers when not in use and to protect PHI from unauthorized access. The incident constituted a breach of the facility's policy and federal HIPAA regulations regarding the privacy and security of resident information.
Failure to Complete Accurate PASRR for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a diagnosed mental disorder, specifically post-traumatic stress disorder (PTSD), had an accurate Preadmission Screening and Resident Review (PASRR) completed. The resident, who had a history of alcohol abuse, major depressive disorder, anxiety disorder, PTSD, depression, adjustment disorder, and hallucinations, was admitted with a Level 1 PASRR that incorrectly indicated no evidence of mental illness. The care plan identified risks related to altered thought processes, and the resident's medical record documented multiple mental health diagnoses. Despite these documented conditions, the PASRR screening did not reflect the presence of a mental disorder, and the resident was not evaluated for specialized mental health care needs as required. During interviews, the resident reported not receiving any services for PTSD since admission and was unaware of any such offerings. The social services designee acknowledged that the PASRR was completed incorrectly and agreed that a Level II PASRR would have been appropriate. The facility's policy requires accurate identification and evaluation of residents with serious mental illness or intellectual disabilities, but this process was not followed, resulting in the failure to identify and address the resident's mental health care needs.
Failure to Individualize Care Plans for Residents with Trauma and Mental Health Needs
Penalty
Summary
The facility failed to review and revise the care plans for two residents with trauma exposure and related mental health needs, as required by their own policies and federal regulations. Both residents had intact cognition and complex psychiatric histories, including diagnoses such as PTSD, depression, anxiety, and adjustment disorder. Despite these diagnoses and documented symptoms, their care plans lacked individualized interventions addressing their trauma triggers, coping mechanisms, and specific behavioral symptoms. For example, one resident reported not being offered any PTSD-related services and was unaware of any trauma-informed interventions in place, while the other resident had not discussed her past traumas with staff and did not recall being offered counseling services since admission. Care plan reviews revealed that interventions were generic and did not specify what would trigger the residents' PTSD, how staff should respond to trauma-related behaviors, or what specific actions should be taken during episodes of altered thought processes or hallucinations. The care plans also failed to address the residents' emotional and psychosocial needs in a person-centered manner, omitting details about their personal histories, trauma experiences, and preferred coping strategies. This lack of specificity meant that staff did not have clear guidance on how to support these residents in managing their mental health conditions. Interviews with staff, including CNAs, LPNs, and the DON, confirmed that care plans are relied upon to guide resident care, especially for unfamiliar residents. The DON acknowledged that trauma-informed care was not addressed in the care plans for these residents and that such information should be included to ensure appropriate care. The facility's policies require individualized, resident-centered care planning that incorporates personal history and trauma exposure, but these requirements were not met for the two residents in question.
Failure to Provide Trauma-Informed and Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to implement trauma-informed and culturally competent care approaches for two residents with diagnosed post-traumatic stress disorder (PTSD) and histories of trauma. Both residents, who were veterans, had intact cognition and multiple mental health diagnoses, including PTSD, depression, and anxiety. Despite these diagnoses, neither resident had individualized care plan interventions that addressed their trauma histories, potential triggers, or specific behavioral symptoms related to PTSD. One resident reported not having discussed her past traumas with staff and did not recall being offered counseling services since admission, while the other resident was unaware that the facility recognized his PTSD diagnosis and had not been offered related services. Review of the residents' electronic medical records and care plans revealed that the interventions listed were generic and did not include trauma-specific strategies, identification of triggers, or guidance for staff on monitoring and responding to PTSD-related behaviors. The care plans lacked person-centered approaches tailored to the residents' unique trauma experiences, as required by facility policy. Additionally, the trauma screening and social services assessments were incomplete or inaccurately documented, with key questions about trauma history and mental health diagnoses marked as "No" despite clear evidence to the contrary in the residents' medical records. Interviews with facility staff, including the social services designee and the director of nursing, confirmed that trauma-informed care was not addressed in the care plans for these residents. Staff acknowledged that information gathered during trauma assessments should be included in care plans to prevent re-traumatization and to guide individualized care. The facility's own policy emphasized the need for person-centered care planning and consistent implementation of care approaches for residents with trauma histories, but these requirements were not met for the two residents in question.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to meet their individual needs.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
A certified nursing assistant (CNA) failed to protect a resident from potential physical abuse during morning care. The resident, who was cognitively intact and had a history of Parkinson's disease, hypertension, spinal stenosis, and falls, reported to multiple staff members that the CNA was upset with him and handled him roughly. The resident sustained an ankle injury and abrasions on both shins during the transfer from bed to wheelchair, and required both scheduled and PRN pain medication for his ankle pain. Staff observed the resident's distress and documented new skin injuries following the incident. In a separate incident, a resident with moderate cognitive impairment and a history of traumatic brain injury, dementia, and psychiatric conditions made unsolicited sexual advances toward another resident. The event was witnessed by a registered nurse, who observed the resident placing his hand inside the shirt of a female resident. Video footage confirmed the inappropriate contact, which lasted approximately twenty seconds before staff intervened. The resident's medication review revealed that his scheduled Depo-Provera injections, intended to help control sexually inappropriate behaviors, had not been administered for two consecutive months due to medication unavailability and scheduling issues. Both incidents involved failures to protect residents from abuse—physical in the first case and sexual in the second. In each case, the deficiencies were identified through resident reports, staff observations, and review of medical and facility records. The events highlighted lapses in staff conduct and medication administration that directly led to residents being exposed to abuse or potential abuse.
Failure to Administer Medications as Ordered Due to Unavailable Medication and Incomplete Error Reporting
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents, resulting in significant medication errors. For one resident with a diagnosis of radiculopathy, a 30-day supply of Gabapentin was delivered, but 49 capsules went missing and the facility could not determine when or how they disappeared. As a result, the resident missed multiple scheduled doses of Gabapentin over several days. Although Gabapentin was available in the facility’s Emergency Kit (E-Kit), nursing staff and a qualified medication aide did not check the E-Kit and assumed the medication was unavailable, leading to further missed doses. Documentation confirmed that the pharmacy had delivered replacement Gabapentin to the E-Kit, but staff failed to utilize it, and the missed administrations were acknowledged as medication errors by the Director of Nursing (DON). Another resident, who had a history of traumatic brain injury, cognitive impairment, and other complex medical conditions, did not receive ordered monthly Depo-Provera injections on several occasions because the medication was not available. Progress notes indicated repeated instances where the medication was not available and orders were sent to the pharmacy, but there was no documentation of administration for multiple months. Medication error reports were completed for some missed doses, but not for all, and the DON confirmed that the facility did not follow its own policy for documenting and reporting all medication errors related to these missed injections. Interviews with staff revealed that the medication reordering process relied on reminders and manual reordering through the electronic medical record system, but lapses in communication and follow-through led to medication shortages and missed doses. The DON reviewed progress notes daily but did not identify all missed doses or ensure that medication error reports were completed as required by facility policy. The facility’s policy required documentation, investigation, and reporting of all medication errors, but these procedures were not consistently followed, resulting in unaddressed medication errors for both residents.
Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident did not receive prescribed Depo-Provera injections as ordered. Documentation revealed that the resident, who had a history of traumatic brain injury, dementia, depressive disorder, seizures, and other significant medical conditions, missed several scheduled doses of Depo-Provera over multiple months due to the medication not being available. Progress notes indicated that the medication was ordered from the pharmacy when unavailable, but there was no documentation that the physician was notified of missed doses on three specific occasions. Additionally, the facility's own policy required physician notification whenever an order was not followed for any reason, including medication unavailability. The director of nursing confirmed that there was no documentation of physician notification for the missed doses on the identified dates. Medication error reports were only completed for two of the missed doses, with physician notification documented for those instances, but not for the earlier missed doses.
Failure to Provide Prompt Incontinence Care Constitutes Neglect
Penalty
Summary
Two certified nursing assistants (CNAs) failed to provide prompt incontinence care to two residents who required assistance with continence. One resident, who was cognitively intact and had a history of paraplegia, pneumonia, and chronic obstructive pulmonary disease, reported that a CNA did not return to provide incontinence care after being called twice during the day shift. The resident remained in a soiled brief until the night shift CNA provided care. Skin assessments prior to the incident noted redness and inflammation in the groin area, but no further skin issues were documented after the incident. Another resident, who had moderate cognitive impairment and diagnoses including ataxic cerebral palsy, muscle weakness, depressive disorder, and epilepsy, was found by a night shift CNA to be soaked in urine. The resident stated that the day shift CNA had not changed her brief. A skin assessment completed prior to the incident noted an impression on the right upper buttock but no redness or open areas. No additional skin issues were documented following the incident. Interviews with facility staff confirmed that the two CNAs responsible for day shift care did not provide timely incontinence care to the residents. The incidents were reported as neglect by the facility, and the staff involved were identified through schedule review and interviews. The failure to provide prompt incontinence care constituted neglect and resulted in a deficiency finding.
Failure to Provide Scheduled Bathing and Timely Skin Rash Treatment
Penalty
Summary
A severely cognitively impaired resident with multiple comorbidities, including sepsis, UTI, COPD, depression, dementia, and diabetes, was admitted to the facility and developed a skin rash characterized by scabbing and abrasions on various parts of the body. Documentation revealed that the resident did not receive any baths from admission through the end of the first month, received only four baths the following month with a two-week gap, and had only one bath before discharge in the final month. Staff interviews confirmed uncertainty regarding the lack of scheduled bathing, with one CNA noting the resident may have been omitted from the bath schedule and another acknowledging the worsening of the resident's skin condition over time. The resident's medical record indicated that staff observed and documented the progression of the skin rash and scabbing, with multiple skin assessments noting the presence of scabs, abrasions, and dry skin. Despite these observations, there was a delay in obtaining physician orders for appropriate topical treatment. Requests for anti-itch cream and topical ointment were made, but there was no immediate response from the physician, and the topical ointment was not started until several days after the initial request. The treatment administration record later showed that topical ointments were administered, but only after a delay. Facility policy required timely assessment, reporting, and documentation of changes in condition, as well as documentation of bathing activities or refusals. However, the resident's lack of scheduled bathing and the delay in obtaining and initiating physician-ordered treatment for the skin rash demonstrated a failure to provide care according to orders and the resident's needs. Staff interviews further revealed gaps in communication and adherence to established procedures for both bathing and skin care documentation.
Failure to Assess and Initiate Care for New Pressure Ulcer
Penalty
Summary
A resident with multiple complex medical conditions, including hemiplegia, stroke, stage IV chronic kidney disease, diabetes, and vascular dementia, was identified as being at high risk for pressure ulcer development, as indicated by a Braden scale score of 18. The resident experienced a change in medical condition and was receiving IV fluids and antibiotics for a urinary tract infection. During personal care, a CNA observed a new skin injury on the resident's buttock and reported it to the unit manager and the nurse responsible for the resident's care. Despite this notification, the responsible RN failed to complete and document an assessment of the new skin injury, did not notify the physician, did not obtain or implement treatment orders, and did not report the new injury to the oncoming shift. Subsequent weekly skin assessments by another RN also failed to document measurements or descriptions of the injury, and there was no physician notification or treatment initiation. When the dressing was reported as coming off, another RN assessed and measured the wound but did not initiate standing wound care orders until the physician could be reached during regular business hours. These lapses resulted in a delay in assessment, physician notification, and initiation of appropriate wound care for the resident's newly discovered skin injury. The facility's process for managing new skin injuries was not followed by multiple staff members, as confirmed by interviews and record reviews. The deficiency was identified through review of documentation, staff interviews, and direct observation.
CNA Applied Dressing Outside Scope; RN Failed to Assess and Notify Physician for New Skin Injury
Penalty
Summary
A certified nurse aide (CNA) observed a new, quarter-sized skin injury on a resident's buttock while providing personal care. The CNA reported the injury to the unit manager/wound care nurse and the registered nurse (RN) responsible for the resident's care. Despite being notified, the RN did not complete or document an assessment of the new skin injury, nor did the RN notify the resident's physician or obtain and implement a physician's order for treatment. The CNA independently applied a dressing to the resident's skin injury, a task that was outside the CNA's professional scope of practice according to the facility's job description. The RN did not instruct the CNA to apply the dressing and was unaware that the CNA intended to do so. The CNA's job description specified responsibilities such as reporting to nursing staff and providing care to maintain skin integrity, but did not include independently applying dressings to skin injuries.
Failure to Initiate CPR and Assess for Irreversible Death in Full Code Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to provide basic life support, including CPR, to a resident who was found unresponsive, despite the resident having a full code resuscitation status. The registered nurse (RN) and licensed practical nurse (LPN) involved did not assess the resident for irreversible signs of death, such as rigor mortis or dependent lividity, before deciding not to initiate CPR. The RN also failed to promptly identify the resident's code status and did not communicate critical assessment findings to the administrator, which delayed the initiation of life-sustaining measures. The resident involved had a history of heart disease, anemia, COPD, chronic peptic ulcer, depression, and alcohol abuse, and was moderately cognitively impaired. She was found unresponsive, cold to the touch, and with stiff limbs by staff. Despite these findings, there was no documentation of a thorough assessment for clinical signs of irreversible death, and the RN left the resident's room to check the code status at the nurses' station instead of using available resources nearby. The LPN confirmed the absence of a heartbeat and noted mottled lower extremities but did not document the change in the resident's medical status in the electronic medical record. The RN did not direct the code response as required, failed to call 911 immediately after identifying the resident's full code status, and did not provide a clear report to the administrator regarding the presence or absence of irreversible death signs. As a result, CPR was not initiated until much later, and emergency medical services took over care upon arrival. The lack of timely assessment, documentation, and response to the resident's change in condition led to the cited deficiency.
Failure to Provide Required Supervision for Resident Outside
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of wandering and falls was allowed to go outside unsupervised. The resident, who had diagnoses including cerebral aneurysm, vascular dementia, and major depressive disorder, was observed by a transportation staff member who held the door open for him but did not notify facility staff. The resident sat on a bench outside, where he subsequently fell, sustaining abrasions to his forehead and right knee, and was sent to the Emergency Department. Review of the resident's care plan indicated that he required supervision when outside due to his tendency to wander, with specific interventions stating that staff should stay with him. Multiple staff interviews confirmed that the resident was not safe to be outside alone and should have been supervised at all times, even when seated. The administrator was unaware of the care plan intervention and acknowledged that the resident was in her line of sight but did not provide direct supervision. The lack of adherence to the care plan and failure to provide adequate supervision led to the resident's fall and injury.
Failure to Adequately Address Resident's Wound
Penalty
Summary
The report details a deficiency in the care provided to a resident who suffered a skin tear on her left lower leg. The resident, who had a moderately impaired cognitive status and multiple serious health conditions including paroxysmal atrial fibrillation and peripheral artery disease, received a laceration on her leg after catching it on her wheelchair. Despite the injury, the on-call care provider decided that the wound could be managed within the facility, and the resident's son was informed of the situation. However, the wound continued to bleed over several days, and the facility staff struggled to manage the bleeding effectively. Interviews with various staff members revealed that there was a lack of adequate supplies, such as steri-strips, to properly care for the wound. The nursing staff, including CNAs and RNs, repeatedly changed the resident's dressing as it became saturated with blood, but the bleeding persisted. Despite the ongoing issue, the decision was made not to send the resident to the emergency department, and the family was not re-notified to make a decision regarding further medical intervention. The resident's condition deteriorated, and she passed away shortly after the incident. The facility's policies on neglect and wound care were reviewed, highlighting a failure to provide necessary and adequate care to prevent harm. The staff did not follow the wound care protocol effectively, and there was a lack of communication and decision-making regarding the resident's worsening condition. The assistant director of nursing and the administrator both expressed that they did not believe anything was done incorrectly, despite the continuous bleeding and lack of appropriate supplies.
Failure to Implement Pressure Injury Prevention for High-Risk Resident
Penalty
Summary
The provider failed to assess and implement preventative pressure injury interventions for a resident who was identified as at risk for pressure injuries. The resident was admitted to the facility with a high risk for skin breakdown, as indicated by a Braden scale score. Despite this, the only intervention in place at admission was heel lift boots. The care plan required the resident to be turned and repositioned every two hours, but this was not consistently implemented, leading to the development of a pressure injury on the resident's coccyx. The resident's electronic medical record showed that a request for a bariatric air mattress and wheelchair cushion was made, but these were not ordered until several days later. Weekly skin assessments were signed off as completed but were not actually performed. Interviews with staff revealed a lack of communication and follow-through regarding the resident's repositioning and skin assessments. The resident's care plan included specific instructions for repositioning and skin care, but these were not effectively communicated or executed by the staff. The facility's policy on skin and pressure injury prevention was not adhered to, as evidenced by the failure to prevent the development of pressure injuries in a resident who was at high risk. The staff interviews highlighted gaps in the documentation and communication processes, which contributed to the oversight in the resident's care. The deficiency was identified as non-compliance with the standard of care expected for preventing pressure injuries.
Failure to Monitor Bowel Management Program and Notify Physician
Penalty
Summary
The provider failed to ensure a bowel management program was monitored for a resident who had multiple diarrhea consistency stools and unintentional weight loss. The resident, who was cognitively intact and had ataxic cerebral palsy, experienced significant weight loss over a three-month period. Despite eating between 50 and 100 percent of her meals and taking dietary supplements, the resident's weight dropped from 115.8 pounds to 93.6 pounds. The resident reported having watery bowel movements with every toileting and often had uncontrolled bowel movements, which she attributed to the medications she was given. The medical record revealed that the resident had 48 bowel movements in a 30-day period, with 33 documented as diarrhea loose. However, there was no documentation indicating that the physician had been notified of the frequent loose stools, and the resident continued to receive both a laxative and a stool softener daily despite the diarrhea. Interviews with staff revealed a lack of communication and awareness regarding the resident's condition. Certified nursing assistants (CNAs) were aware of the frequent loose stools and charted the consistency in the electronic medical record system, but registered nurses (RNs) were unable to view this information due to system updates. The MDS coordinator expected nurses to hold the laxative medication when the resident had loose stools, but there was no documentation to support that this was done. The physician assistant was not informed of the resident's condition and had not been notified of the frequent loose stools, which could have contributed to the resident's weight loss. The consulting dietitian was also unaware of the loose stools and depended on staff to notify her of changes in the resident's condition. The facility's policies and job descriptions did not include specific instructions for reporting frequent loose stools to the nurse or physician, nor did they mention holding laxatives or stool softeners during episodes of loose stools. The lack of appropriate and necessary notification to the physician assistant and registered dietitian about the resident's condition, combined with the continued administration of laxatives and stool softeners, contributed to the resident's unintentional weight loss and frequent diarrhea. The facility's failure to monitor and manage the resident's bowel program appropriately led to this deficiency.
Medication Administration and Documentation Failures
Penalty
Summary
The nursing facility failed to ensure proper medication administration and documentation by its staff. One registered nurse (RN) mixed a resident's pills with applesauce and left nutritional supplements and Mirilax on the dining table without ensuring the resident consumed them. The RN documented that the medication was administered, but observation revealed that the resident did not consume all of the Mirilax, leading to inaccurate documentation on the Medication Administration Record (MAR). Another incident involved a licensed practical nurse (LPN) who administered lorazepam and morphine to a resident but failed to document the administration on the MAR. The LPN acknowledged the oversight and confirmed that the medications were given before changing the resident's Foley catheter, as supported by a progress note in the resident's electronic medical record (EMR). Additionally, the facility did not accurately document the administration of tube feeding and water flushes for a resident with a feeding tube. The MAR lacked proper documentation for the nighttime tube feeding and water flushes, and there were discrepancies in the recorded amounts of tube feeding administered. The director of nursing confirmed that staff were expected to observe residents during medication administration and document it immediately, which was not followed in these cases.
Medication Administration Errors
Penalty
Summary
The provider failed to ensure medications were administered as ordered for two residents. For Resident 14, the controlled drug records for clonazepam revealed that the resident was given a 0.25 mg dose in the evening instead of the ordered 0.5 mg dose on multiple occasions. The Medication Administration Records (MARs) inaccurately documented that the 0.5 mg dose was given, while the actual administration was 0.25 mg. This discrepancy was confirmed by a count of the medication blister packs and the documentation logs. The Director of Nursing confirmed that these medication errors occurred and were not reported, investigated, or followed up on as required by the facility's policy. For Resident 32, during a morning medication pass, the registered nurse (RN) administered lisinopril without first reconciling a discrepancy between the pharmacy label and the MAR order. The pharmacy label included instructions to hold the medication if the systolic blood pressure was less than 90, but this instruction was missing from the MAR. The RN administered the medication without taking the resident's blood pressure, as required by the original order. The Director of Nursing confirmed this medication error and noted that no error reports were completed or investigated for this incident either. The facility's policy mandates that staff compare medication labels to MAR orders and reconcile any discrepancies before administration, which was not followed in these cases.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The provider failed to ensure that two residents had prescription medications accurately labeled and that a certified medication aide (CMA) did not alter a prescription medication label. For Resident 14, the Medication Administration Record (MAR) indicated a daily dose of 0.25 mg clonazepam, but the medication blister pack label stated the dose as 'as needed.' The discrepancy was confirmed by the Director of Nursing (DON), Assistant DON, and CMA. Additionally, the CMA had altered the medication label by covering the 'as needed' instruction with a black permanent marker, which is against the facility's policy that only the pharmacy provider can make such alterations. For Resident 32, the registered nurse (RN) administered lisinopril during the morning medication pass. The pharmacy label on the blister pack included an instruction to hold the medication if the systolic blood pressure was less than 90, but this instruction was not present on the resident's MAR. The DON confirmed that staff are expected to compare each blister pack label to the MAR order and reconcile any discrepancies before administering medication. The facility's policies from September 2018 and May 2016 were reviewed, which stated that medication labels should not be altered by nursing personnel and that discrepancies should be checked against the prescriber's orders.
Infection Control Deficiencies in Hand Hygiene and Glove Use
Penalty
Summary
The provider failed to ensure proper infection control practices were followed by an occupational therapist (OT) and an assistant director of nursing (ADON). The OT, while preparing to transport a resident to therapy, did not remove her gloves, perform hand hygiene, or put on a clean pair of gloves after assisting the resident with her wheelchair and adjusting her oxygen tubing. Additionally, the OT used the same gloves to wipe saliva from the resident's mouth and then exited the room without performing hand hygiene. The OT confirmed that she should have performed hand hygiene after glove removal. The ADON, while assisting a resident with toileting, washed her hands but used her wet hands to turn off the faucet handle before drying her hands with a paper towel. She then put on a clean pair of gloves to clean urine spots off the floor, removed her gloves, and washed her hands again, but used her wet hands to adjust the faucet handle. The ADON confirmed that her wet hands should not have touched the faucet handle and that a clean paper towel should have been used to turn off or adjust the faucet handle. The facility's hand hygiene policy was reviewed and it was noted that hand hygiene should be completed after contact with objects in the immediate vicinity of the resident and that the use of gloves does not replace hand hygiene.
Latest citations in South Dakota
Failure to Follow EBP and Hand Hygiene Practices: Staff did not wear gowns or gloves, did not perform hand hygiene, and did not clean an EZ stand lift after providing high-contact care to a resident on EBP with a Foley catheter. Staff also provided toileting care to a resident with open stage II pressure ulcers without gowns, and a housekeeper handled resident-room surfaces and items with unclean hands while cleaning rooms. Facility policy required gown and glove use for EBP, cleaning reusable equipment between residents, and hand hygiene after resident contact and glove removal.
A resident with severe cognitive impairment, TBI, and dementia with behavioral disturbances used a one-piece jumpsuit identified as a restraint intervention to address genital exposure and related behaviors. The EMR showed consent and physician approval, but the quarterly MDS and care documentation did not show whether the garment remained needed, whether less restrictive alternatives had been tried, or whether restraint reduction or elimination had been considered. Staff interviews confirmed the resident had not worn the garment in a long time, and the DON stated there was no restraint-specific documentation form to track its use or reassess the need for it.
Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
Failure to assess, document, and report new pressure ulcers: A resident with a pelvic fracture and intact cognition developed stage II pressure ulcers on both inner buttocks and a new pressure ulcer on the heel. Staff interviews and record review showed the DON/wound nurse did not document the heel wound or notify the MD, did not notify the MD when the left buttock ulcer was identified, and wound monitoring was not completed daily as required by the facility's own process.
Staff failed to follow a resident’s care-planned transfer needs. The resident had severely impaired cognition, a moderate fall risk score, and required dependent assistance with transfers, including a Hoyer lift with 2 staff or a sit-to-stand lift. Two CNAs lifted her by the underarms and pivoted her instead of using the ordered transfer method, and one CNA stated she did not use a gait belt because the resident was too tiny. The DON acknowledged the transfers were improper and unsafe because staff did not follow the care plan or Kardex.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Staff failed to honor several residents’ stated preferences regarding where they undressed for bathing, affecting their dignity and privacy. One resident reported that a CNA repeatedly undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his expressed wish to undress in the shower room. Other residents described similar experiences, stating that the CNA did not ask their preferences and routinely undressed them in their rooms before covering them with a sheet or blanket and taking them to the tub or shower room. Staff interviews confirmed that residents, particularly those requiring a mechanical lift, were typically undressed in their rooms and then transported covered, and the DON stated that facility protocol was to follow resident preference, consistent with the written dignity and privacy policy.
A resident reported that a contracted travel CNA placed hands down his pants while he was in bed, which he described as groping and not part of his usual care routine. Two RNs received this allegation; one counseled the CNA but did not notify leadership and did not know the required reporting time frame, while the other, who knew the 2‑hour reporting requirement, also failed to promptly inform the DON or administrator, delaying notification to state authorities and omitting contact with law enforcement and the ombudsman. In a separate incident, a resident’s family member reported suspected financial abuse to the social services designee, who informed the administrator, but the concern was not reported to the state agency or investigated as an abuse allegation; instead, the family was only given contact information for outside agencies. These actions did not follow the facility’s abuse policy requiring immediate internal reporting, prompt investigation, and timely reporting of all abuse and misappropriation allegations to the state agency.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
Failure to Follow EBP, Equipment Cleaning, and Hand Hygiene Practices
Penalty
Summary
Infection prevention and control practices were not followed during care for a resident on enhanced barrier precautions (EBP) who had a Foley catheter. During a transfer from a wheelchair to a recliner using an EZ stand lift, two CNAs/RMAs did not wear gowns or gloves, did not perform hand hygiene after the transfer, and one CNA/RMA placed the lift outside the resident’s room without cleaning it. One of the CNAs/RMAs stated she was expected to wear a gown and gloves for the transfer and remove them afterward, and the other stated she should have worn a gown and gloves and cleaned the lift after use. A second resident had open stage II pressure ulcers to both buttocks and a new pressure ulcer on the right heel, but was not placed on EBP. During observed toileting assistance, an RN and a CNA wore gloves but did not wear gowns while providing care to the resident’s open buttock wounds. The CNA applied barrier cream to the pressure ulcers and the rest of the buttocks. The RN stated the resident did not need EBP because the wounds did not have drainage, and the ADON/IP stated the resident was not on EBP because the pressure ulcer was not chronic. Housekeeping staff also did not follow hand hygiene practices while cleaning resident rooms. A housekeeper removed a mop head with bare hands, touched door handles without washing hands, and used unclean hands while moving between rooms and handling resident items and bathroom surfaces. The housekeeper stated she was supposed to wash her hands after cleaning a bathroom, after mopping, and between rooms, and the director of food and nutrition/housekeeping and housekeeping supervisor confirmed staff were to wash hands before and after glove use, after bathroom cleaning, and before and after mopping. Facility policy stated EBP required gown and glove use for high-contact care such as transferring and toileting, reusable equipment was to be cleaned and disinfected between residents, and hand hygiene was the primary means to prevent the spread of healthcare-associated infections.
Lack of Documentation for Ongoing Use of One-Piece Garment Restraint
Penalty
Summary
The provider failed to document whether one resident who used a one-piece jumpsuit as a restraint intervention was a candidate for restraint reduction, a less restrictive restraint method, or restraint elimination. The resident had severe cognitive impairment, a history of traumatic brain injury, and dementia with behavioral disturbances. He was observed seated in his wheelchair at breakfast and later in his recliner, repeatedly moving his feet, rocking his trunk, and placing his hand in and out of the waistband of his sweatpants. His EMR showed that the jumpsuit had been identified as a restraint intervention and that the resident's spouse had signed informed consent for its use. The record showed the resident had ongoing behaviors involving fondling himself and exposing his genitals, and staff requested physician approval for a one-piece garment to protect his dignity and prevent exposure to others. The physician approved the request. The quarterly MDS indicated the resident used a trunk restraint on a less-than-daily basis, and the MDS nurse's note stated that when available the resident would wear the one-piece jumpsuit. However, that assessment did not include documentation supporting continued use or discontinued use of the garment, and there was no indication that other alternatives had been tried. The behavioral tracking record documented other targeted behaviors, but fondling and exposing his genitals were not identified as targeted behaviors on that assessment. During interviews, an LPN stated the jumpsuit's zipper was on the backside of the garment, restricting the resident's access to his genitals, and said he had not worn it in a long time because of physical and cognitive decline. A CNA also stated she had not seen him wear the garment. The MDS nurse found the jumpsuit hanging in the resident's closet and acknowledged she did not know whether staff had completed restraint-related documentation. The DON stated there was no restraint-specific form to document when the jumpsuit was worn, what precipitated its use, what less restrictive interventions were tried, or how long it was worn, and acknowledged that without such documentation the quarterly assessment could not fully determine whether the jumpsuit remained needed or could be discontinued. The facility's restraint policy required least restrictive use, ongoing reevaluation, and quarterly review for restraint reduction, less restrictive methods, or elimination.
Failure to Follow Ordered Urology Consultation
Penalty
Summary
The nursing facility failed to follow a physician-ordered urology consultation for a resident with urinary retention and a Foley catheter. The resident had been hospitalized for a left femur fracture, and hospital records showed the Foley catheter was removed and later reinserted after a failed trial without catheter. After discharge to the skilled nursing facility, the physician was faxed about discontinuing the Foley catheter and responded to start Alfuzosin for 4 days and then attempt a trial without the catheter. When that trial failed, the physician ordered the Foley restarted and follow-up with urology. Subsequent physician progress notes in February, March, and April documented referral to urology for further evaluation and care, and the resident’s catheter care plan addressed Foley care but did not include a plan for removing the catheter. During interviews, an LPN stated she knew the resident was expected to be seen by a urologist but it had not yet occurred and she was not sure why. The DON and ADON/IP stated the physician was expected to call the urologist to make the referral and that the urology office would then confirm the appointment time. The ADON/IP recalled discussing the urology consultation with the physician during January rounds, but confirmed she did not discuss the status of the consultation during February, March, or April rounds and had no other discussions with the physician about it. The DON acknowledged the failure to follow the January physician-ordered urology consultation was 100% on the facility.
Failure to assess, document, and report new pressure ulcers
Penalty
Summary
The provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers for one resident who had returned to the facility from the hospital with a pelvic fracture and weakness and had an intact BIMS score of 15. The resident had a stage II pressure ulcer to the right inner buttock identified on 4/6/26, and later a stage II pressure ulcer to the left inner buttock was identified on 4/27/26. The record showed wound assessments on the right inner buttock, but the report states the wound assessment documentation was not completed weekly as required, and the physician was not notified when the left inner buttock ulcer was identified. The resident was observed sitting in a wheelchair on a Roho pressure-relief cushion and stated she had an open sore on her bottom. Staff interviews confirmed she had pressure ulcers on both inner buttocks, and a CNA reported finding a new pressure ulcer on the resident's right heel that was boggy and dark red and purple in color. An LPN stated the resident had stage II pressure ulcers to both inner buttocks and that the new right heel pressure ulcer had been found the previous day. The DON/wound nurse later stated she was not aware of the right heel pressure ulcer and could not find documentation of it or documentation that the physician had been notified. The record review showed the resident's wound assessments were completed on several dates for the right inner buttock ulcer, with measurements and descriptions documented, and the care plan addressed pressure ulcers to both inner buttocks. However, the DON/wound nurse stated nurses did not monitor pressure ulcers daily and that weekly skin assessments were the routine process. The provider's policy required nurses to document and report pressure ulcers, and the change-in-condition policy required physician notification within 24 hours for a significant change of condition. The DON/wound nurse stated she did not notify the physician when the left inner buttock ulcer was identified and planned to wait until the physician rounded at the facility later.
Unsafe Transfers Not Followed for a Resident With Care-Planned Lift Needs
Penalty
Summary
The nursing home failed to ensure safe transfers for resident 11, who had severely impaired cognition, a moderate fall risk score, and care-planned transfer needs requiring dependent staff assistance. Her revised care plan stated that she usually required a Hoyer lift with staff assist x 2 for transfers when she was not placing her feet on the ground for a pivot transfer with a gait belt and staff assist x 1-2, or a sit-to-stand lift. The resident was observed in the dining room being lifted by CNA F and CNA/RMA E, who each placed an arm beneath her underarms, raised her to standing, pivoted her, and lowered her into her wheelchair. CNA F later transferred the resident from the wheelchair to a recliner in the same manner and stated the resident could not bear her full weight and that she did not use a gait belt because the resident was too tiny. A separate observation showed CNA/RMA G using a sit-to-stand lift to transfer resident 11 from her wheelchair to the toilet and referring to the Kardex to confirm that a mechanical lift was required. The DON/wound nurse stated therapy assessed residents' mobility and transfer needs, those recommendations were added to the care plan, and the care plan information was then transferred to the Kardex so staff would know how to care for the resident. The DON acknowledged that CNA/RMA E and CNA F improperly and unsafely transferred resident 11 by failing to follow the transfer recommendations in the care plan and Kardex.
Failure to Maintain Safe Bed Systems and Prevent Accidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bed environment free from entrapment hazards and to provide adequate supervision and accident prevention for multiple residents. Surveyors observed that several residents had loose side rails or grab bars and mattresses that were not secured or properly fitted, creating gaps between the rails, mattress, and bedframe. One resident’s bilateral side rails could move away from the bed one to two inches, and there was a five‑inch gap between the top of his mattress and the headboard. Another resident, who was legally blind and had previously fallen out of bed during a dream and sustained a brain bleed, had a left side rail that could move three inches away from the mattress; he reported telling a CNA and his daughter about the loose rail about a week earlier. A third resident used bilateral side rails for bed mobility; her right rail could move two to three inches away from the bed, the openings within the rails measured three and one‑half inches wide by 13 inches high, and there was a seven‑inch gap between the foot of her mattress and the footboard. Surveyors also found that the facility’s entrapment assessments and maintenance audits were incomplete or inaccurately documented. Review of the maintenance logbook for side rail inspections from January through April showed that only zone 1 (the opening within the side rail) was consistently assessed, while the other six FDA‑defined entrapment zones were often marked as not applicable, including zone 7 (the space between the mattress and headboard or footboard) even for residents without bed rails. In some months, all seven zones were documented as not applicable for numerous residents known to have side rails, and some residents with side rails were not included in the audits at all. The DON was unsure if there was a specific entrapment assessment policy and believed maintenance handled these assessments, while also acknowledging missing documentation for side rail assessments, consents, and physician orders, and that some side rails were installed without proper documentation. Additional deficiencies related to accident prevention and supervision were identified in several facility‑reported incidents. One resident with a history of stroke and left‑sided weakness fell from his bed while trying to remove his socks after a CNA left his bed at waist height; his care plan at that time did not specify a required bed height, and he was later diagnosed with a minor closed head injury and abrasions. Another resident, care planned to require two staff for transfers and use of a sit‑to‑stand lift, was transferred by a single contracted CNA using a sling that was too small and the wrong hook, causing back pain; the resident and his family reported that he was often transferred by only one staff member despite the care plan. A cognitively impaired resident at risk for elopement exited through a door whose alarm had been deactivated during daytime hours so visitors could enter and exit, walked outside in very cold weather, and re‑entered through another door after about 15 minutes. A further resident, on anticoagulant therapy, fell while transferring herself to the bathroom and hit her head; she had fallen 11 times in 30 days, and the provider failed to implement, review, and revise interventions to reduce her fall risk. These events collectively demonstrate failures to follow care plans, maintain environmental safety devices such as alarms and bed systems, and provide adequate supervision to prevent accidents. The surveyors determined that these failures, particularly the unsecured side rails and unassessed mattress gaps, created a risk for entrapment injury or harm and issued an Immediate Jeopardy finding under F689 related to accident hazards and supervision. Observations throughout the building confirmed multiple safety concerns with side rail installation, maintenance, and bed zone assessments, including loose rails and significant gaps between mattresses and headboards or footboards. Facility leadership and maintenance staff acknowledged that gaps between mattresses and bed ends and loose side rails posed a risk for entrapment and injury, and that entrapment zone measurements and assessments had not been consistently completed according to FDA guidance and facility policy.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Honor Resident Bathing and Undressing Preferences
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity, respect, and self-determination regarding bathing and undressing practices. One resident reported in a facility reported incident that on his bath days, a CNA undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his stated preference to undress in the shower room. During a later interview, this resident stated that the CNA continued this practice, that it made him uncomfortable, and that it happened all the time. The DON stated that the bathing protocol was to follow each resident’s preference for where to undress, and that the CNA had been informed of this resident’s preference. The resident’s care plan documented his need for assistance with dressing but did not include his specific bathing or undressing location preferences. Additional interviews showed that this practice extended to other residents and was not individualized based on resident choice. The CNA acknowledged awareness of the resident’s preference but stated that all residents were undressed in the shower room, while another CNA described a typical routine in which residents with limited mobility who required a mechanical lift were undressed in their rooms, covered with a blanket, and then transported to the shower room. Another resident reported seeing the first resident transported to the shower room covered only by a blanket and stated that the CNA did not ask where he preferred to undress, instead beginning to undress him after announcing it was time for a bath. A third resident stated that the same CNA transferred him from bed to a chair, covered him with a white sheet, and took him to the tub room without asking his preferences, and that he had seen other residents transported in the same manner. These practices conflicted with the facility’s Resident Dignity & Privacy Policy, which required staff to groom and dress residents according to their preferences and to maintain privacy during care.
Failure to Timely Report and Investigate Allegations of Sexual and Financial Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and initiate required investigations into two separate allegations of abuse, including sexual and possible financial abuse. One resident reported that at approximately 6:00 a.m. a contracted travel CNA placed hands down his pants while he was in bed, allegedly to check if he was wet, which the resident described as groping that made him feel cheap. The resident stated he typically did not receive nighttime incontinence checks, as he used a urinal and was usually only awakened for early morning blood sugar checks or lab draws. He reported this incident to two RNs, one of whom acknowledged that it was not appropriate for staff to put their hands down a resident’s pants to check incontinence products. Despite this, the nurses who received the allegation did not immediately report it to the DON, administrator, or state agency as required by facility policy and federal guidelines. One RN spoke with the contracted travel CNA to “educate” her but did not notify anyone else and did not know the required reporting time frame. Another RN, who was aware of the process and the two-hour reporting requirement to the state health department, also failed to promptly report the allegation to the DON or administrator, resulting in a delay until late morning before leadership became aware. At the time leadership was notified, the allegation had not yet been investigated, and law enforcement and the ombudsman had not been contacted, even though the allegation involved possible sexual abuse. A second deficiency arose when a resident’s family member reported concerns of suspected financial abuse to the social services designee, who then informed the administrator. Instead of treating this as an abuse allegation requiring reporting and investigation under the facility’s abuse and neglect policy, the administrator did not report it to the state health department, citing a lack of detailed information. The social services designee and administrator only provided the family with contact information for external agencies such as the state’s attorney and adult protective services. The facility’s own policy required that all allegations and suspicions of abuse, including misappropriation of property and exploitation, be immediately reported to the administrator or designee, investigated by the administrator or designee, and reported to the state agency within two hours, but these procedures were not followed for either the sexual abuse allegation or the suspected financial abuse concern.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
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