Avantara Mountain View
Inspection history, citations, penalties and survey trends for this long-term care facility in Rapid City, South Dakota.
- Location
- 916 Mountain View Road, Rapid City, South Dakota 57702
- CMS Provider Number
- 435040
- Inspections on file
- 23
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avantara Mountain View during CMS and state inspections, most recent first.
Non-compliance with F684 occurred when a resident was left without repositioning or continence care for about nine hours overnight due to an unupdated CNA assignment sheet and lack of hand-off communication during a split shift. Another resident, whose care plan required Cares in Pairs because of behavioral and safety concerns, was assisted with toileting by a single CNA, contrary to the documented intervention. In a separate event, a resident who activated a call light for incontinence care waited roughly one and a half to two hours before a CNA changed her brief, after the assigned CNA turned off the call light, returned to another room, and later dismissed reports of the resident hollering, leading another CNA to eventually provide the needed continence care.
The facility failed to adhere to professional standards in medication management, with nurses signing off on controlled substances counts prematurely and a resident self-administering an inhaler without proper assessment. Additionally, an RN documented medication administration before actually administering it, contrary to policy.
The facility failed to properly monitor residents returning from dialysis, as evidenced by inaccurate documentation of post-dialysis vital signs for three residents. A resident with end-stage renal disease reported inconsistencies in monitoring, and records showed discrepancies in vital sign documentation. Another resident also experienced inconsistent vital checks, with records showing outdated data. Staff interviews revealed flaws in the process, with pre-populated data not being updated, contrary to the facility's dialysis management policy.
The facility experienced a medication error rate of 18.75% due to improper administration of diclofenac sodium gel and Flonase nasal spray by staff, contrary to orders and policies. A resident's nebulizer treatment was documented but not administered, and Nystatin powder was given without a physician's order. The DON confirmed these discrepancies.
The facility failed to ensure proper labeling and storage of medications and medical supplies. A resident's Ativan prescription lacked a pharmacy label, preventing verification against the physician's order. Outdated medical supplies were found in storage rooms, and insulin pens for two residents were not labeled or dated correctly. Staff interviews revealed unclear responsibilities for managing outdated supplies, contributing to these deficiencies.
The facility failed to ensure proper cleaning of a whirlpool tub and adequate hand hygiene during medication administration. A CNA did not follow the posted cleaning instructions for the tub, and multiple staff members, including RNs and an LPN, did not perform hand hygiene as required by the facility's policy. Additionally, an RN did not adhere to proper hand hygiene while providing care to a resident with a yeast infection.
The facility failed to ensure care plans for two residents were updated and followed. One resident's care plan lacked specific interventions for manipulative behaviors, while another's inaccurately listed medication, leading to discrepancies in care. Staff interviews confirmed these issues, highlighting a need for accurate and timely care plan updates.
A resident with a history of multiple health issues was administered an antibiotic for a potential UTI without meeting clinical criteria. The facility failed to obtain a urinalysis and did not follow proper documentation and communication protocols. The infection preventionist incorrectly documented that microbiological criteria were met, and the facility's Antibiotic Stewardship Program policy was not followed.
A deficiency was identified when a resident was transported from a dialysis appointment on a facility-operated bus. The bus driver noticed the resident tilted backward in her wheelchair due to a malfunctioning front clamp strap, which failed to secure the wheelchair properly. This incident potentially placed the resident at risk for harm or injury.
A resident inflicted self-harm requiring surgery due to inadequate pain management. Despite having orders for pain medications, there was no documentation of administration, and pain levels were not properly assessed or managed. Staff interviews revealed inconsistencies in following pain management policies.
Failure to Provide Timely Repositioning, Continence Care, and Care Plan–Directed Assistance
Penalty
Summary
Non-compliance with F684 occurred when one resident was not repositioned or provided continence care for approximately nine hours during an overnight shift. Camera footage confirmed that between 8:30 p.m. and 5:41 a.m., the resident did not receive repositioning or incontinence care. The facility’s investigation identified that the staff assignment sheet had not been updated to reflect that two CNAs were splitting the overnight shift, and there was no hand-off communication between the CNAs when one left and the other began the split shift. As a result, the resident’s routine checks and care needs were not carried out during that time period. Additional non-compliance involved another resident whose care plan required "Cares in Pairs," meaning two staff were expected to be present when providing care due to the resident’s history of manipulative behavior, verbal abuse toward staff, recording staff without their knowledge or permission, and making false accusations or statements about staff. Despite this care plan intervention, a CNA assisted the resident with toileting alone, without a second staff member present. The incident was discovered during the investigation of an unrelated event, and there were no adverse consequences reported as a result of this failure. The resident was observed later receiving assistance from two CNAs and reported satisfaction with her care and caregivers. A third incident of non-compliance occurred when a resident who was assigned to a CNA activated her call light for incontinence care and experienced a significant delay before her brief was changed. At the time the call light was activated, the assigned CNA exited another resident’s room, entered the resident’s room, turned off the call light, and then returned to the previous room instead of providing care. Later, the CNA was approached by a family member of another resident and appeared to respond to that request. More than an hour after the initial call light activation, the resident was heard hollering from her room. Another CNA informed the assigned CNA, who dismissed the hollering as the resident wanting her dinner tray removed. A different CNA was then asked to check on the resident and found that the resident had a bowel movement coming out of her brief, with fecal matter on the bedding that appeared to have been present for some time. The resident later confirmed she had soiled her brief and that it took approximately one and a half to two hours before a CNA came to change her. Across these three events, the deficiencies centered on failures to provide timely and appropriate care according to orders, care plans, and residents’ needs and preferences. In the first case, lack of updated assignments and hand-off communication led to missed repositioning and continence care. In the second, a CNA did not follow a clearly documented care plan requiring two staff for care. In the third, the assigned CNA did not respond to a resident’s call light and vocal requests for incontinence care in a timely manner, resulting in prolonged exposure to soiled conditions, even though the resident reported that her care was usually provided promptly and that this was an isolated event.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The report identifies deficiencies in the handling and documentation of controlled medications by nursing staff at the facility. Specifically, it was observed that a registered nurse (RN) and two licensed practical nurses (LPNs) signed the controlled substances count sheet as the offgoing nurse before their shifts had ended and before completing the required medication count with the oncoming nurse. This action was contrary to the facility's policy, which mandates that both the oncoming and offgoing nurses complete and verify the accounting of all controlled medications together at each shift change. Additionally, the report highlights a failure in the assessment and documentation process for a resident self-administering medication. A resident with moderate cognitive impairment and a diagnosis of dementia was observed self-administering an inhaler without prior documented assessments to determine the appropriateness and safety of self-administration. The facility's policy requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications, which was not completed until after the resident was observed using the inhaler. Furthermore, the report notes an instance where an RN documented the administration of medications before actually administering them to a resident. This practice was against the facility's medication administration policy, which requires that the administration be recorded immediately after the medication is given. The director of nursing confirmed the expectation that medications should be administered before being documented as given.
Inadequate Monitoring of Post-Dialysis Residents
Penalty
Summary
The facility failed to ensure proper monitoring of residents returning from dialysis treatments, as evidenced by the lack of timely and accurate documentation of post-dialysis vital signs for three residents. Resident 26, who has end-stage renal disease and other significant health conditions, reported inconsistencies in receiving assistance and monitoring upon returning from dialysis. Her electronic medical record showed discrepancies in the dates of recorded vital signs, indicating that the documented post-dialysis vitals were not taken on the actual day of her return from dialysis. Similarly, Resident 33, who also requires regular dialysis, reported that her vital signs were not consistently checked upon her return, and her records showed similar issues with the documentation of vital signs from previous days being used instead of current data. Resident 85, who has multiple health issues including end-stage renal disease and orthostatic hypotension, also had discrepancies in the documentation of his post-dialysis vital signs. Interviews with staff, including a registered nurse and the director of nursing, revealed that the process for recording post-dialysis assessments was flawed, with pre-populated data from previous assessments not being updated with current information. The facility's policy on dialysis management was not adhered to, as it required the review and documentation of post-dialysis information upon the residents' return, which was not consistently done.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The provider failed to ensure proper medication administration, resulting in a medication error rate of 18.75%. Observations revealed that RN G and UMA K did not use the measurement device for diclofenac sodium 1% gel, leading to incorrect dosing for three residents. Additionally, RN I administered Flonase nasal spray in excess of the physician's order for one resident. These actions were contrary to the provider's medication administration policy and the manufacturer's recommendations. Another deficiency was noted when a resident's nebulizer treatment was documented as administered, but the resident reported not receiving it. The nebulizer medicine cup was found with clear liquid, indicating the treatment had not been given. The DON confirmed the resident's statement and acknowledged the discrepancy between the documentation and the actual administration. Furthermore, RN N applied Nystatin powder to a resident without a current physician's order. The resident had a severe yeast infection, and the medication was administered without proper documentation in the electronic medical record. The DON confirmed that all medications should have a current physician's order before administration, which was not adhered to in this case.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and medical supplies, leading to several deficiencies. One resident's prescription for Ativan, an anti-anxiety medication, was not accurately labeled, as the medication bottle lacked a pharmacy label to confirm the resident's identity, dosage information, or instructions for use. This oversight prevented nursing staff from verifying the medication against the physician's order before administration. Additionally, outdated medical supplies, including Ambu bags and hypodermic safety needles, were found in the medication storage rooms, indicating a lapse in the removal of expired items. Further deficiencies were noted with insulin pens for two residents, which were not labeled with pharmacy labels to confirm the identity of the medication, dosage, or usage instructions. The insulin pens were also not dated with the opening date, and staff were unable to locate information on the expiration period after opening. The facility's policy on medication storage did not address the disposal of outdated medical supplies, contributing to the oversight. Interviews with staff revealed a lack of clear responsibility for checking and removing outdated medical supplies, further highlighting the deficiencies in medication and supply management.
Inadequate Infection Control Practices
Penalty
Summary
The provider failed to ensure proper cleaning of the whirlpool (WP) tub by a certified nursing assistant (CNA) who was temporarily assisting with bathing residents. The CNA did not follow the posted cleaning instructions, which required running disinfectant through the aerator holes/jets and allowing the area to stand for at least 10 minutes. Instead, the CNA used a simplified cleaning process that did not meet the facility's standards, as confirmed by the director of nursing (DON). Additionally, there were multiple instances of improper hand hygiene during medication administration by four staff members, including registered nurses (RN), a licensed practical nurse (LPN), and an unlicensed medication aide (UMA). These staff members failed to perform hand hygiene before and after administering medications to residents, and in some cases, did not follow contact precautions for residents on isolation. The facility's hand hygiene policy, which emphasizes handwashing as a primary means to prevent infection spread, was not adhered to during these observations. One resident with a yeast infection was observed receiving personal care from an RN who did not follow proper hand hygiene protocols. The RN washed her hands for only a few seconds between glove changes and did not wash her hands at all before applying clean gloves at one point. This was contrary to the facility's hand hygiene policy, which requires at least 20 seconds of handwashing. The DON confirmed that the expectation was for staff to follow the hand hygiene policy, which was not met in these instances.
Failure to Update and Follow Care Plans for Two Residents
Penalty
Summary
The provider failed to ensure that the care plans for two residents were followed, updated, and revised promptly to reflect their current status and care needs. For Resident 26, interviews with staff revealed that the resident had manipulative behaviors and false accusations, but the care plan lacked specific non-pharmacological interventions to address these behaviors. The social service director acknowledged that the interventions were not listed, and the process to review and update care plans was interdisciplinary. Additionally, the care plan indicated that personal care should be provided with two staff members present, but there was no evidence that this intervention was consistently documented or followed. For Resident 51, the care plan inaccurately reflected that the resident was taking Plavix, an antiplatelet medication, when in fact, the resident was prescribed Eliquis, a blood thinner that requires different monitoring. Interviews with nursing staff confirmed the discrepancy, and the director of nursing noted that medications were not typically specified on care plans due to potential changes. However, the expectation was for care plans to be updated as the resident's care and needs changed. The facility's care plan policy emphasized the importance of individualized, resident-centered care planning and the need for care plans to be updated to reflect current care needs.
Failure to Ensure Clinical Criteria for Antibiotic Use in Suspected UTI
Penalty
Summary
The provider failed to ensure that a resident who received an antibiotic for a potential urinary tract infection (UTI) met the clinical criteria for its use. The resident, who had a history of diabetes, peripheral vascular disease, depression, insomnia, and anorexia, was reported to have mood changes, low appetite, and dysuria. A medical provider ordered a urinalysis (UA) and started the resident on cefdinir, an antibiotic, for a potential UTI. However, the UA was not obtained, and the antibiotic was administered without confirming the UTI diagnosis through appropriate clinical assessment or microbiological evidence. Interviews with facility staff revealed that the expected documentation and communication protocols were not followed. A Suspected UTI SBAR form, which should have been completed by the nurse, was not found at the second-floor nurses' station. Additionally, there was no documentation explaining why the UA was not obtained, whether further attempts were made to collect the urine sample, or if the medical provider was informed of the inability to obtain the UA. The infection preventionist incorrectly documented that microbiological criteria were met, despite the lack of a UA. The facility's Antibiotic Stewardship Program policy emphasizes the importance of appropriate antibiotic use, which was not adhered to in this case.
Deficiency in Wheelchair Securement on Facility Bus
Penalty
Summary
A deficiency was identified when a resident was being transported from a dialysis appointment to the facility on one of the provider's buses. During the transport, the bus driver noticed through the rear-view mirror that the resident was tilted backward in her wheelchair. Upon further assessment, it was discovered that one of the front clamp straps used to secure the wheelchair was extended, indicating a malfunction. The tie-down system, which is designed to automatically tighten when the strap loosens due to normal bus movements, failed to function as intended. This malfunction in the tie-down system potentially placed the resident at risk for harm or injury. The incident highlights a failure in ensuring that the wheelchair was safely secured during transport, which is a critical aspect of resident safety. The deficiency was identified through a review of the facility-reported incidents, interviews, and record and policy reviews conducted by the South Dakota Department of Health.
Inadequate Pain Management Leading to Resident Self-Harm
Penalty
Summary
The provider failed to ensure adequate pain management for a resident who inflicted self-harm that required surgical treatment. The resident, who was cognitively intact and had no signs of depression, inflicted a stab wound to his abdomen and was transferred to the hospital for surgery. The incident revealed non-compliance in the pain management process, including inadequate pain documentation, failure to document the administration of pain medication, and incomplete pain assessments. The resident had multiple diagnoses, including rheumatoid arthritis and other conditions that could cause pain. Despite having physician orders for various pain medications, there was no documentation that Tylenol, which was ordered as needed for pain, had been administered. The resident's pain levels were documented as high on several occasions, but there was no evidence that any interventions were provided to relieve his pain. Interviews with staff revealed inconsistencies in the pain management process. The admitting nurse failed to enter standing orders for pain medication into the electronic medical record, and there was a lack of documentation of pain assessments and interventions. The provider's policies on pain management and following physician orders were not adequately followed, contributing to the resident's unmanaged pain and subsequent self-harm.
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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