Avantara Norton
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux Falls, South Dakota.
- Location
- 3600 South Norton Avenue, Sioux Falls, South Dakota 57105
- CMS Provider Number
- 435039
- Inspections on file
- 40
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Avantara Norton during CMS and state inspections, most recent first.
Two residents experienced failures in timely implementation of physician orders and provider notification. One resident with cognitive impairment, respiratory failure, pneumonia, and a urinary catheter had a UA/UC ordered after increased confusion, but catheter change and urine collection were delayed and inconsistent, and an antibiotic order faxed for a UTI was left on a reception fax machine and never started before a later order changed therapy based on culture results. Lab reports showing Enterobacter cloacae and susceptibility to a different antibiotic were not consistently documented as reviewed, and the resident continued to exhibit confusion and flank pain until transfer to the ER. Another resident with ESRD on dialysis, hypotension, hypertension, and heart failure had orders for Midodrine with BP parameters and daily Metoprolol, but Midodrine was not given on dialysis mornings and Metoprolol was rarely given on dialysis days, without notifying the physician. Very low BPs were recorded without documented provider notification or repeat checks, despite a TAR requiring monitoring for post-dialysis complications. Interviews and policy review showed expectations to follow orders and notify physicians of abnormal labs, omitted medications, and changes in condition, which were not met in these cases.
Two residents at high risk for pressure ulcers did not receive consistent, individualized prevention and treatment measures, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment and high Braden risk, fully dependent on staff for mobility and hygiene, was repeatedly observed in bed with the head of bed elevated and sliding down, without documented q2h repositioning, individualized pressure-relief interventions, or consistent use of barrier cream, and CNAs and restorative staff were unaware of specific pressure-prevention measures for her. Another resident with multiple comorbidities, prior healed pressure ulcers, and a high Braden score developed recurrent stage II and III pressure ulcers to the coccyx and gluteal fold, a left heel DTI, and a left lateral leg stage II ulcer; ordered wound treatments were not documented as completed on at least one ordered date, he was not on a defined turning schedule despite being largely bedfast, and heel offloading and use of heel boots were inconsistently implemented and documented. In both cases, staff interviews and record review showed that facility practices did not consistently align with the facility’s own skin and pressure injury prevention policy requiring q2h repositioning, appropriate support surfaces, and systematic offloading for bedfast residents.
The deficiency centers on unsafe resident transfers and unsecured chemicals. A resident with hemiplegia and severe cognitive impairment, care planned for a one-person sit-to-stand (STS) lift transfer, was instead manually transferred by a CNA without the lift, during which the resident’s legs gave out, he was lowered to the floor, hit his head, and later was found to have a subdural hematoma. Another resident with severe cognitive impairment and documented inability to meet STS criteria was nonetheless assessed and care planned for STS transfers, while staff and family intermittently pivot transferred her without a gait belt and with inconsistent use of mechanical lifts, amid reports that pocket care plans and Kardex information were not kept up to date. Additionally, surveyors repeatedly observed an open tub room with unlabeled and labeled chemical spray bottles accessible on the tub, and an unattended housekeeping cart in the dining room with toilet bowl cleaner and other disinfectants unlocked and reachable by residents, contrary to staff statements that such rooms and chemicals were to be secured.
A resident with dementia, a prior femur fracture, polyneuropathy, and hospice care showed repeated signs of pain during transfers and personal care, including moaning, yelling, screaming, and grimacing. Staff expressed uncertainty about whether his behaviors reflected pain or anxiety, and pain assessments were inconsistent between a 10-point scale and PAINAD. An LPN and CNAs stated he likely had pain when moved, but morphine was not consistently given, and the resident’s distress was observed before PRN morphine was administered.
A resident with heart disease and anxiety reported not receiving his ordered nitroglycerin patches, despite the MAR showing the RN documented administration and the evening LPN finding no patches on his chest to remove. The resident said he worried all day and night after repeatedly asking for the medication. Record review and supply count showed a discrepancy, and the DON concluded the resident likely missed his morning dose. The facility’s medication policies required meds to be given as prescribed and errors to be documented and investigated.
The facility failed to consistently honor resident preferences and care‑planned frequency for bathing, resulting in multiple residents going six to ten days or longer between baths despite being scheduled for twice‑weekly showers or baths. Several residents, including those with impaired and intact cognition, reported missed or inconsistent baths, needing to repeatedly remind CNAs, and being told they were skipped due to other residents waiting longer, staffing shortages, or equipment issues. Observations included a resident with long, jagged fingernails and urine odor who reported missed scheduled showers. Review of EMRs and the bath schedule showed numerous missed baths without documented refusals or valid reasons, while the grievance log and resident council minutes documented ongoing complaints from multiple residents about not receiving baths as scheduled. Nursing staff acknowledged receiving complaints and that residents sometimes went more than a week without bathing, despite a facility policy stating residents have the right to choose timing and frequency of bathing and requiring documentation of bathing activity or refusals.
Two cognitively intact residents with significant ROM and mobility limitations did not receive their care-planned restorative nursing programs as ordered. One resident with DM, neuropathy, above-knee amputation, and CKD reported increasing stiffness and weakness and stated that staff no longer brought her for exercises; records showed only sporadic lower extremity and kinetic bike sessions over several months despite physician orders and a care plan for regular AROM and restorative activities. Another resident with RA, polyneuropathy, and prior fractures, who used a power wheelchair, reported not receiving her prescribed exercise program and feeling she was losing strength; her MDS and restorative documentation showed no completed restorative exercises or standing with a walker despite a detailed restorative care plan. Therapy staff and RAs confirmed written restorative recommendations and expectations for 3–6 sessions per week, but reported that two RAs were responsible for about 44 residents, could not see all residents daily, prioritized those more willing or independent, and were unsure when these two residents last received restorative exercises, while the DON acknowledged awareness of staffing difficulties and confirmed the minimal restorative services actually provided.
Inaccurate MDS coding was found for PASRR status, insulin use, and psychotropic medications. Two residents with approved PASRR Level II determinations were coded as not having PASRR Level II, one resident receiving glargine and aspart insulin was coded as not receiving insulin, and two residents had incorrect psychotropic medication coding, including one coded for an anti-anxiety med that was not ordered and another coded as not receiving an antipsychotic despite an order for Rexulti. The MDS RN verified the errors, and the DON stated the MDS should be coded accurately.
Baseline care plans were not completed within 48 hours of admission for some residents, and several newly admitted residents were not shown to have had their plans reviewed with them or offered a copy within the required timeframe. Interviews and record review showed that staff sometimes scheduled the care conference several days after admission, including for residents admitted late in the week, and documentation was missing for multiple residents. One resident also reported not recalling any review of the plan, while another disputed inaccurate content in the plan.
Staff failed to maintain dignity, hygiene, and privacy for multiple dependent residents. A resident with severe cognitive impairment and depression was left in bed in nightclothes with dried food and juice on her body and linens, and was observed with a dried substance on her nose that was not cleaned over time, despite her reliance on staff for all personal care. Another cognitively impaired resident, dependent on staff for hygiene and dressing, was repeatedly observed wearing a heavily soiled shirt, with food in his beard and thick residue on his fingers, and continued to spill coffee on himself in the dining room without staff assistance or interventions; there was no documentation that he refused care. A third cognitively impaired resident with severe mental illness and risk for abuse and neglect was provided incontinence care while standing at the sink in a shared room without adequate use of the privacy curtain or window blinds, allowing his roommate and potentially others to see him during intimate care, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment, dementia, metabolic encephalopathy, a history of stage II pressure ulcers, and a urinary catheter was left in a dining room for about ten hours without receiving care as outlined in the care plan. The resident’s plan required repositioning every two hours, substantial assistance with toileting hygiene every two to three hours, monitoring of urine output each shift, and extensive assistance with transfers and wheelchair mobility. On the day of the incident, the resident was brought to the dining room in the morning and not returned to his room until evening, and the assigned CNA and LPN did not provide the scheduled care during this time. The facility’s investigation determined that this failure to follow the care plan and provide necessary care for an extended period constituted neglect.
A resident with a history of making allegations of rough care and a care plan requiring all care to be provided by two caregivers was assisted by a single CNA, contrary to the documented "cares in pairs" intervention. The care plan identified manipulative behavior and alleged mistreatment, and specified that two caregivers should be present to address the resident’s needs and observe the entire care session. On one occasion, the CNA entered the room alone and began providing care, after which the resident reported to an LPN that the CNA had been rough, leading to a deficiency citation for failure to follow the resident’s care plan under F684.
Two residents had inconsistent code status documentation across the EMR banner, signed forms, and pocket care plans. One resident’s signed form indicated DNR while the EMR and care plan listed Full Code, and another resident’s signed form indicated DNR while the EMR banner and physician order listed DNR with OK to intubate and the care plan listed Full Code. Staff, including a CNA/CMA, LPN, DON, and the administrator, confirmed the discrepancies and noted the risk that the residents’ wishes may not be followed in an emergency.
A dietary aide failed to follow hand hygiene and food safety practices during meal service in the Central dining room. She touched her face, hair, pants, and a resident, then handled and served resident food without washing or sanitizing her hands, used bare hands to apply butter to a resident’s bread, washed her hands for only about 4 seconds, and put a milk lid back on a container after it fell on the floor. The DM confirmed the expected hand hygiene and food handling practices, and the facility policy required handwashing for at least 20 seconds before and after handling food and resident contact.
Housekeeping staff failed to follow hand hygiene and glove-use practices while cleaning resident rooms and did not follow the manufacturer’s required contact time for a Multi-Surface Peroxide cleaner. One housekeeper handled trash, cleaning supplies, and room surfaces with the same gloves on without hand hygiene between tasks, while another entered a resident room wearing gloves without hand hygiene and wiped surfaces immediately after spraying the disinfectant. The cleaner’s label required a 1- to 2-minute wait before wiping dry, and staff interviews showed uncertainty about the product’s disinfection contact time.
A CNA applied Nair, a chemical hair removal cream, to a cognitively impaired resident’s perineal area at the resident’s request, using a product kept in the room without a physician’s order or secure storage. The resident, who had MS, CVA with hemiplegia/hemiparesis, DVT, epilepsy, and required extensive assistance, was unable to remove the cream herself. The next day an LPN noted redness and soreness in the peri area during routine wound care and confirmed with the CNA that Nair, not shaving, had been used. Hospital records later described chemical burns to the resident’s thighs and labia and cellulitis from the burn. Staff interviews and facility policy indicated that over-the-counter products like Nair require a physician’s order, must be locked, and that chemical hygiene products should be applied by nursing staff, not CNAs, but these requirements were not followed in this case.
A resident admitted with a stage II coccyx pressure ulcer and high Braden risk did not receive timely wound assessment, documentation, or implementation of ordered pressure-relief interventions. Hospital transfer orders for Q2H repositioning, heel elevation, moisture protection, and specialty support surfaces were not fully or promptly carried out, and heel boots and an air mattress were delayed. Family reports and LPN assessments revealed that Mepilex dressings placed on admission remained unchanged for an extended period, there were no active wound treatment orders in the EMR for several days, and the wound nurse did not assess the wound until eight days after admission, by which time it was documented as a stage III ulcer with slough and maceration. Additional pressure areas, including a right ankle ulcer, were incompletely assessed and documented, nutritional supplement orders for wound healing were not started promptly, and observations showed inconsistent use of Prevalon boots and lack of a cushion when the resident was seated, all contrary to the facility’s own pressure injury prevention program requirements.
A resident with muscular dystrophy, intact cognition, unsteadiness, and decreased mobility had a care plan requiring extensive assist of two staff for transfers. A CNA, aware of this requirement, attempted to transfer the resident alone by lifting her under the arms from a wheelchair to the bed. Because the bed was not in a low position, the CNA could not complete the transfer, turned to return the resident to the wheelchair, and the resident began to slide, was lowered to the floor, and her leg struck the wheelchair, causing two skin tears and knee pain. Facility documents, including the CNA job description and care plan policy, required CNAs to know and follow resident care plans and to safeguard skin integrity.
Two residents with cognitive impairments eloped from the facility by exiting through the front door without staff knowledge, after being mistaken for visitors and due to the door alarm system being bypassed with staff badges. Staff were not fully aware of which individuals were at risk for elopement, despite the presence of an elopement binder with photos and information, leading to inadequate supervision and failure to prevent accident hazards.
A cook served soup at a temperature above the facility's policy, leading to a resident spilling the hot soup and experiencing mild skin redness. The incident occurred during in-room meal service due to a flu outbreak, and the resident had a history of hot liquid safety assessments with interventions adjusted over time.
Staff did not consistently use required PPE, such as gowns and gloves, when providing care to residents on enhanced barrier precautions, and failed to clean shared equipment like mechanical lifts after each use. Multiple residents reported that staff typically wore gloves but not gowns, and urinals without lids were left in rooms. Additionally, a urine spill remained uncleaned for hours, and staff were unaware until notified. These actions did not follow facility infection prevention policies.
The facility did not provide appropriate care for pressure ulcers and failed to prevent new ulcers from developing, as evidenced by lapses in monitoring, treatment, and documentation protocols.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety but does not provide further details about the specific events or individuals involved.
An LPN administered another resident's medications, including Zolpidem and Eliquis, to a resident with an allergy to Zolpidem and no prescription for blood thinners. The error occurred after the LPN became distracted, mislabeled medication cups with similar first names, and failed to follow established identification protocols. No adverse reactions were observed.
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 a deficiency related to resident safety.
The facility did not ensure that two residents received their PRN controlled pain medications according to physician orders, with doses administered at intervals shorter than prescribed. Additionally, a resident with congestive heart failure and a recent hip replacement experienced a significant weight gain over two days, but was not re-weighed nor was the physician notified, contrary to facility policy.
A registered nurse diverted controlled pain medications prescribed to two residents by signing out oxycodone but not always administering it, as shown by discrepancies between the narcotic sign-out sheets and the MAR. One resident was cognitively intact and reported no missed medication, while the other had severe cognitive impairment. The facility's process did not include cross-checking the MAR with narcotic records, allowing the diversion to go undetected until the RN's behavior prompted further investigation.
A report reveals significant delays in response to call lights in a LTC facility, affecting residents' well-being. Residents experienced long wait times for assistance, leading to frustration, incontinence, and unmanaged pain. Staffing shortages contributed to the issue, with staff often unable to provide timely care. Despite facility policies, call light response times were not consistently met, impacting resident satisfaction and care.
The facility failed to properly complete and format Medicare notices for three residents before their discharge from Medicare Part A skilled services. The deficiencies included the use of outdated forms, missing provider information, and unclear explanations of non-covered services. Interviews revealed a lack of policy and awareness regarding the updated forms, with MDS coordinators responsible for delivering the notices.
The facility failed to maintain proper infection control practices for residents using respiratory devices, such as oxygen concentrators, CPAP machines, and nebulizers. Observations showed that equipment was not cleaned or stored according to policy, with items like nasal cannulas found on the floor and filters coated in dust. Staff interviews revealed confusion about responsibilities, and medical records lacked documentation for necessary maintenance tasks.
A survey found that a facility failed to maintain proper food safety standards in residents' personal refrigerators, with incomplete temperature logs and recorded temperatures exceeding safe limits. Food items were not consistently labeled or dated, and staff interviews revealed a lack of clarity and adherence to policies regarding refrigerator maintenance and temperature monitoring.
The facility experienced a widespread system breakdown affecting infection control practices, care plan development, and responsiveness to residents' concerns. Failures included improper use of PPE, inadequate hand hygiene, and poor maintenance of oxygen concentrators. Additionally, care plans were not updated timely, and medication administration did not meet professional standards, impacting the psycho-social well-being of 94 residents.
The governing body of the facility did not operate in a manner that ensured the quality of life and well-being for all 94 residents. During a survey, several deficiencies were identified, indicating that the provider failed to ensure residents received quality care, as referenced under F582, F656, F658, F675, F695, F812, F835, and F880.
A facility was found deficient in infection control practices, including improper hand hygiene during wound care, delayed implementation of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, and inadequate labeling of personal care items. Staff failed to perform hand hygiene between glove changes, and EBP signage and PPE were not timely placed for residents requiring them. Personal care items lacked proper labeling, increasing the risk of cross-contamination.
Two residents' care plans were not updated to reflect their current needs. One resident's care plan lacked focus on respiratory status and use of oxygen and CPAP, while another resident's care plan was outdated following the removal of a feeding tube. Staff interviews indicated that care plan updates were the responsibility of the interdisciplinary team, but these updates were not made in accordance with facility policy.
Two residents experienced deficiencies in medication administration and physician notification. A resident with Parkinson's disease did not receive timely medication and had significant weight gain without physician notification. Another resident with cognitive impairment had low blood pressure readings without consistent physician notification or medication adjustments. Facility staff interviews revealed non-adherence to established procedures for monitoring and reporting changes in residents' conditions.
A deficiency occurred when a facility failed to communicate with hospice and a resident's family about changing an overlay air mattress to an alternating low air loss mattress, leading to the resident's discomfort. The facility's policy preferred the latter, but the change was made without notifying hospice or the family, resulting in complaints and a lack of documentation in the resident's medical record.
A resident with severe cognitive impairment was neglected by a CNA who failed to provide timely care, resulting in the resident being incontinent for an unknown period and developing stage 2 pressure ulcers. The CNA assumed another CNA had provided care, but camera footage showed the resident was not checked on for several hours. Interviews revealed an expectation for residents to be checked every two hours, but no specific policy enforced this practice.
A resident receiving IV antibiotics for osteomyelitis had her tunneled chest catheter improperly removed by an untrained RN, who mistook it for a PICC line. The facility lacked policies and training for catheter management, leading to this deficiency. Interviews revealed that staff, including the RN, had not received adequate training on IV medication administration or catheter procedures.
A facility failed to ensure a resident's care plan accurately reflected the treatment needs for a tunneled chest catheter. The resident's medical record incorrectly referred to the catheter as a PICC line, and the care plan did not specify the route for IV antibiotics or address dressing changes. The physician's orders were also inconsistent with the resident's actual catheter type, and vascular access evaluations omitted mention of the catheter. The resident had moderate cognitive impairment and was hospitalized at the time.
A resident was admitted to a facility, but a baseline care plan was not created within the required 48 hours, leading to unmet care needs and severe pain. The care plan was delayed by five days, and staff interviews confirmed the oversight. The facility's policy mandates timely care planning to guide caregivers, which was not followed in this instance.
A resident with a history of wounds developed and worsened pressure ulcers due to the facility's failure to implement preventive interventions. The resident's care plan lacked repositioning measures, and heel protectors were not initially used. Observations and interviews revealed issues such as delayed call light responses, inadequate documentation, and the resident's refusal of care due to pain. The facility-acquired wounds worsened, highlighting deficiencies in care planning and intervention.
Significant medication errors were identified in a LTC facility involving three residents. One resident did not receive her immunosuppressant medication due to a transcription error and untimely ordering. Another resident did not receive Lorazepam during episodes of muscle twitching and seizures. A third resident missed multiple doses of insulin and other medications, with inadequate documentation and communication. The DON acknowledged these issues, and the responsible nurse had resigned.
Two residents reported receiving cold meals due to improper reheating and serving practices. Food items were left on the counter for extended periods, and staff failed to consistently check temperatures before delivery. Despite awareness and attempts to address the issue, the deficiency persisted.
The facility failed to maintain a clean and sanitary environment in the main kitchen and two kitchenettes, with issues such as grease and dust on ventilation hoods, fruit flies, leaking sinks, and mold-like substances. Unlabeled food items and insects were found in kitchenettes, and cleaning tasks were not consistently completed despite being documented. The dietary manager and administrator were aware of some issues, but the actual cleanliness did not match the documented tasks.
A resident's right to refuse a shower and her care plan preferences were not honored when a CNA, unfamiliar with the resident's care needs, insisted on an early morning shower due to incontinence. Despite the resident's refusal and preference for evening showers, the CNA proceeded, leading to the resident feeling manhandled and expressing anger. The incident revealed a communication breakdown and failure to adhere to the resident's care plan.
A resident reported that a CNA was rough with her, forcing her to wake up early and take a shower due to incontinence, and physically pushing her into a chair. The incident was not immediately reported to the administrator, delaying the investigation process. The administrator learned of the situation through a grievance form the following day, which constituted non-compliance with immediate reporting requirements.
Substantial compliance was confirmed after a phone interview with a hospice liaison. The numbers for three nurse's stations were provided to the hospice provider for faxing physician's orders, including new medication orders. This ensured proper communication channels for receiving critical medical information.
The provider failed to ensure adequate supervision and safety measures to prevent hot liquid burns for residents. One resident suffered a burn from hot water due to incorrect documentation of her safety evaluation, and another resident was observed handling hot coffee independently despite requiring staff assistance.
A resident with multiple diagnoses experienced severe pain due to the provider's failure to follow physician orders for pain medication before scheduled wound care. Pain assessments and medication administration were inconsistently documented, leading to inadequate pain management. The resident's pain was not effectively managed, resulting in significant distress and a subsequent hospital admission.
Failure to Follow Physician Orders and Notify Providers for Infection Management and Dialysis-Related Care
Penalty
Summary
The deficiency involves failures to follow physician orders in a timely manner and to notify providers of significant clinical information for two residents. For one resident with moderate cognitive impairment, respiratory failure, pneumonia, and an indwelling urinary catheter, the physician ordered a UA/UC after the resident’s son reported increased confusion and requested urine testing. The order for catheter change and urine collection was received and noted, but the catheter change documented on the treatment record as due on one date was not completed until early the next morning. Lab reports show urine samples collected on two different dates and times, with one sample having been collected and then recollected. The resident’s son reported being told that a urine sample had sat in the refrigerator too long and had to be recollected, and that the facility did not start the initially ordered antibiotic while the culture was pending. The lab ultimately reported Enterobacter cloacae complex in high colony counts, and the physician ordered cefuroxime, then later discontinued it and ordered nitrofurantoin based on susceptibility results. The cefuroxime order, faxed on a Friday, was not implemented because it remained on a fax machine in the front reception area over the weekend and was not found until the following Tuesday, at the same time the later order to stop cefuroxime and start nitrofurantoin was found. The cefuroxime order was not noted as reviewed by staff, and the preliminary and final culture reports, including susceptibility results showing the organism was not susceptible to cefuroxime but was susceptible to nitrofurantoin, were not consistently documented as reviewed with clear dates and staff identifiers. Progress notes document ongoing confusion, flank pain, and the resident’s belief that there was urine in her oxygen tubing, as well as the son’s concerns and request for transfer to the emergency room. The DON later documented that her investigation found the 7/11 cefuroxime order had not been started because it was discovered only when the 7/15 order to stop it and start nitrofurantoin was located, and interviews revealed uncertainty about why the UA was recollected and that the incident investigation did not address the delayed UA collection or lack of on-call physician notification for preliminary lab results. For a second resident with intact cognition and diagnoses including ESRD on dialysis, hypotension, hypertension, and heart failure, physician orders directed dialysis three times weekly, Midodrine three times daily for hypotension with a parameter to hold if SBP was 120 or greater, and daily Metoprolol Succinate ER for hypertension without hold parameters. The March MAR shows the resident did not receive Midodrine on the mornings of dialysis days and received Metoprolol only once on a dialysis day during a specified period, with no documentation that the physician was notified of these omissions. Dialysis records show pre-dialysis BPs in the low-normal range, and the MAR documents very low BPs on one evening and the following morning, with no documentation that the provider was notified of these low readings. The TAR required monitoring for post-dialysis complications, including hypotension symptoms, twice daily on dialysis days, but only one day in the month reflected documented symptoms. Interviews with nursing staff and the DON confirmed expectations that physician orders be processed within the shift, that abnormal labs and out-of-parameter vitals be reported, and that Midodrine be given before dialysis when within parameters, but also revealed uncertainty about processing timelines, lack of a facility policy on vital sign parameters, and that the physician was not notified about the inconsistent administration of Midodrine and low blood pressures. Facility policies required following all physician orders and notifying the physician when orders were not followed or when there was a significant change in status, but these were not adhered to in these cases.
Failure to Implement Individualized Pressure Ulcer Prevention and Treatment for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and individualize pressure ulcer prevention and care for two residents at high risk for skin breakdown, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment, diabetes, depression, and high Braden risk was dependent on staff for hygiene, repositioning, and transfers. On admission, she had no skin breakdown but was identified as at risk. Her care plan initially addressed potential skin impairment but did not include individualized repositioning or pressure-relief interventions beyond standard admission practices. Staff and leadership later acknowledged that the pressure ulcer prevention measures in place before her ulcer developed were standard for all admissions and not tailored to her specific risk factors. For this resident, documentation showed blanchable redness to the buttocks on a skin assessment, followed by identification of a facility-acquired abrasion to the left buttock and coccyx and additional undescribed areas on the backs of both thighs. The next day, the abrasion on the left buttock was documented as a stage II pressure ulcer, which later increased in size. Observations on multiple days showed the resident lying in bed on her back with the head of the bed elevated and her body bent at the chest, with staff acknowledging that this positioning increased the risk of shearing when she slid down in bed. Interviews revealed that she could not turn herself in bed and required staff assistance for repositioning, yet there was no documentation that she was turned every two hours, and the DON could not find evidence that she refused repositioning or barrier cream. CNAs and a restorative aide reported not knowing what pressure prevention interventions were in place for her, and one CNA left her in bed all day because the resident did not respond when asked if she needed anything, despite the resident’s inability to use the call light or reposition herself. The second resident had multiple serious medical conditions, including spinal stenosis, chronic kidney disease, atherosclerotic heart disease, dysphagia, and protein-calorie malnutrition, and was assessed as high risk for pressure ulcers on the Braden scale. He had a history of multiple pressure ulcers and other wounds that had previously healed, but subsequent skin evaluations documented recurrent redness and pressure areas, including a right gluteal fold pressure ulcer and coccyx involvement. Progress notes identified a bleeding open area under the right buttock, reclassification of a right gluteal fold lesion from MASD to a pressure ulcer, and later documentation of a large coccyx pressure area, a left lateral heel DTI, and a left lateral lower leg stage II pressure blister. His care plan listed multiple active pressure injuries and interventions such as an air mattress, pressure-redistributing cushions, wound treatments, and weekly wound monitoring. Despite these identified wounds and orders, the record showed that ordered wound care treatments were not documented as completed on at least one ordered date, and the DON agreed that if treatments were not signed as completed, they were not done, and that wounds would worsen if treatments were missed. Interviews with nursing leadership and the wound nurse indicated that the resident was not on a formal repositioning schedule, even though standard practice was to reposition residents every two hours, and that his heels were offloaded and repositioned only “as needed.” Staff reported that he often refused to get up in his wheelchair and refused heel lift boots, but refusals and effective approaches were not consistently documented. A PA-C stated she would expect preventative measures such as an air mattress to prevent recurrence of pressure ulcers, and the DON and RN unit manager confirmed that an air mattress was ordered only after multiple pressure injuries were documented. The facility’s own Skin and Pressure Injury Prevention Program policy required offering repositioning at least every two hours for bedfast residents, considering off-loading when the head of bed was elevated, and using special mattresses as indicated, but the documented care and staff interviews showed gaps between these policy requirements and the actual implementation of pressure ulcer prevention and treatment for this resident. Overall, for both residents, surveyors identified failures to consistently implement and document individualized pressure ulcer prevention measures such as scheduled repositioning, appropriate use of pressure-relieving surfaces, barrier creams, and heel offloading, as well as failures to ensure staff understood and followed care plan interventions. These failures occurred despite both residents being clearly identified as high risk for pressure injury and, in the second case, having a documented history of prior pressure ulcers and multiple active wounds.
Unsafe Transfers and Unsecured Chemicals Leading to Resident Injury and Exposure Risk
Penalty
Summary
The deficiency involves failures to ensure safe transfers in accordance with resident care plans and to secure hazardous chemicals from resident access. One resident with hemiplegia following a stroke and severe cognitive impairment, who was care planned to transfer with one staff using a sit-to-stand lift, was transferred by a CNA without the lift from the toilet to a wheelchair. During this transfer, the resident’s legs gave out, he was lowered to the floor, and his head struck the wall, resulting in a skin tear on his left forearm, a bump on the back of his head, and elevated blood pressure and pulse. A CT scan later revealed a subdural hematoma. The DON reported that the CNA had been educated that same morning on the importance of following resident care plans, and the CNA stated she did not use the stand lift because she believed she could complete the transfer faster without it. A second resident with senile degeneration of the brain and severely impaired cognition was also not consistently transferred according to her assessed needs and care plan. Her care plan initially indicated use of a sit-to-stand lift, but a lift assessment documented that she could not bear at least 50% of her weight on one leg, could not sit upright without physical assistance, and could not follow simple instructions, which meant she did not meet the criteria for a sit-to-stand lift. Despite this, the assessment summary still indicated she was to use a sit-to-stand lift for bed-to-chair transfers, and she was care planned to use a sit-to-stand lift until later revised to a full-body mechanical lift. The resident’s family member reported concerns about transfers, including that staff did not use a gait belt, that she had assisted staff with pivot transfers, and that staff sometimes used a sit-to-stand lift and sometimes pivot transferred the resident with two staff. A CNA/CMA described pivot transferring this resident with the assistance of the family member by placing their arms under the resident’s arms and moving her from bed to a bath chair, during which the resident did not follow directions or move her feet, and the CNA/CMA held the resident up while quickly pulling the bath chair under her. Documentation and communication tools used by staff to determine transfer methods were not consistently accurate or up to date. Staff reported relying on the Kardex and pocket care plans to determine how residents should be transferred, and multiple staff acknowledged that pocket care plans were not always kept current. For the second resident, the pocket care plan at one point indicated she was a pivot transfer with one staff, while her family stated she required at least two staff for a pivot transfer and had previously used a mechanical lift in another facility. Later, the undated pocket care plan for her hallway indicated she was to be transferred with a full-body mechanical lift and sling. The DON and administrator confirmed that the initial lift assessment for this resident showed she was not a candidate for a sit-to-stand lift, yet she was care planned to use one. The deficiency also includes unsecured hazardous chemicals accessible to residents in a bathtub room and in the main dining area. On multiple observations, the blue hallway bathtub room door was open with no staff present, and a pink crate on top of the bathtub contained two spray bottles, one labeled Multi-Surface Peroxide cleaner with warnings that it causes skin irritation and serious eye damage, and another unlabeled bottle two-thirds full of an unknown liquid. Staff, including a CNA and RN, stated the bathtub room doors were supposed to be closed and locked to prevent resident access and exposure to unsecured chemicals, and the DON and regional nurse consultant confirmed the presence of the labeled and unlabeled chemicals and that the unlabeled bottle did not contain water. In the main dining room, an unattended housekeeping cart was observed with residents present and no staff nearby. The cart contained an open bottle of toilet bowl cleaner on an unlocked portion of the cart, and additional chemicals, including Multi-Surface Peroxide cleanser and Micro Kill foaming disinfectant cleaner, were stored in a lockable compartment that was left unlocked, with the keys on top of the cart. The administrator verified that the chemicals were not secured from resident access and that the bathtub room was supposed to be closed, locked, and accessible only by staff, and that chemicals were expected to be stored in their original labeled containers in a secure location.
Inconsistent pain assessment and delayed treatment for a resident with advanced cognitive impairment
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with advanced cognitive impairment, a displaced right femur fracture, polyneuropathy, and hospice services. The resident was ordered scheduled acetaminophen and tramadol, with PRN morphine 5 mg every two hours for pain or dyspnea. During multiple observations, the resident was heard moaning, yelling, and screaming while staff were providing care or moving him, and his face was repeatedly described as grimacing, red, and showing signs of pain. Staff also described him as rigid and difficult to interpret because of anxiety, crying, and unusual vocalizations. On several occasions, staff members acknowledged that the resident likely had pain during transfers and personal care, but there was inconsistency in how his pain was assessed and treated. One CNA stated it was hard to determine whether he was actually in pain, while another CNA believed he probably had pain when moved and thought it would be a good idea to medicate him before frequent movement. An LPN stated the resident was often feeling pain when moved and transferred and did not feel hospice was managing his pain appropriately. Another LPN stated she usually tried morphine if he seemed in pain, but also said he was tough to read and sometimes seemed anxious rather than in pain. The resident’s pain assessments were inconsistent, with some documented using a 10-point pain scale and others using PAINAD. Staff interviews showed uncertainty about whether the resident could reliably use the 10-point scale because his cognition was not intact and he typically gave only one-word responses. During one observation, the resident was heard moaning and yelling while staff were in the room providing care, and morphine was given only after the resident had already been vocalizing distress. The facility also reviewed the resident’s diagnosis history and added pseudobulbar affect to his record after staff questioned his behaviors, although later review of VA discharge documentation showed no such diagnosis listed before admission.
Missed nitroglycerin patch dose
Penalty
Summary
The facility failed to ensure that a resident with a history of heart disease received his physician-ordered nitroglycerin transdermal patches as prescribed. Resident 44 had diagnoses and care plan concerns including anxiety, atherosclerosis, HTN, PVD, unstable angina, CKD, obesity, anemia, and TIA, and his order directed that two nitroglycerin patches be applied daily at 8:00 a.m. and removed at 7:59 p.m. The resident reported that he did not receive his nitroglycerin patch medication on the morning of 3/23/26 and said he spent the day and night worrying that something terrible would happen to him. He also stated that he repeatedly asked the day nurse for the medication and was told to wait. The March 2026 MAR documented that RN F administered the nitroglycerin patches at 8:00 a.m. on 3/23/26, but later that evening LPN G documented, “Per resident patches were not applied this AM.” When LPN G removed the patches that evening, she found there were no patches on the resident’s chest to remove. In a written statement, RN F said she tried to give the resident his nitro patch in the dining room, but he said later in his room, and she gave them to him later when he came back to his room. However, the resident stated that he did not receive the medication at all that day. The discrepancy was identified during interviews and record review after the resident reported the missed dose. The DON and administrator reviewed the medication supply and found 60 patches had been dispensed, 20 doses were documented as given, and 22 patches remained, leaving one dose more than expected. The DON concluded the resident had not received his 3/23/26 morning dose. LPN G stated she did not question why there were no patches to remove or report it because she assumed there was a valid reason. The provider’s medication administration guidelines stated medications are to be administered as prescribed, and the medication errors policy required errors to be documented, investigated, reported, and reviewed.
Failure to Honor Resident Bathing Preferences and Scheduled Bathing Frequency
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor residents’ rights to choose and receive bathing at the frequency specified in their care plans and preferences. Multiple residents who preferred bathing at least twice weekly did not consistently receive baths or showers as scheduled, and staff did not consistently document refusals or reasons for missed baths. For one resident with severely impaired cognition, the care plan dated 3/25/26 indicated a preference for two baths per week, yet electronic records from 1/28/26 through 3/25/26 showed she received a bath on 3/9/26 and 3/16/26, refused on 3/13/26, was marked as “not available” on 3/20/26 without any supporting documentation that she was out of the facility, and had no documentation of being offered or receiving a bath on 3/23/26. A family member reported concerns that this resident had only received one shower since admission and raised these concerns to the administrator. Another resident with moderately impaired cognition had a care plan dated 3/25/26 indicating a preference for two baths per week. The bath schedule showed he was to receive baths or showers twice weekly on specific days, and there was no documentation of refusals. However, bathing records from 1/28/26 through 3/25/26 showed gaps of six and seven days between some baths, including a seven‑day interval before a bath on 2/21/26 and a six‑day interval before a bath on 3/13/26. This resident reported that there were times he did not receive a bath for a week, that he had to repeatedly remind staff to get a bath, and that the days he was bathed were inconsistent, sometimes occurring every other day and other times with a week between baths. A cognitively intact resident with a care plan preference for two baths per week was scheduled for baths on two specific days each week, but bathing documentation showed missed baths on multiple dates with no refusals recorded. As a result, there were intervals of seven and ten days between baths. This resident stated he did not receive the showers he was supposed to and was unsure if he would receive a scheduled shower on the day of interview. Another resident with moderately impaired cognition, whose care plan indicated a preference for two to three showers per week and who was scheduled for showers on Sundays and Thursdays, had multiple missed showers without documented refusals and repeated six‑day gaps between bathing. During observation and interview, this resident had long, jagged fingernails, smelled of urine, and reported that showers were sometimes not provided on scheduled days or were changed, and that staff had told him he would not get a shower because the shower was being repaired. The facility’s own bath schedule listed specific days for each of these residents to receive baths or showers, but documentation and resident interviews showed that these schedules were not consistently followed. The grievance log from November 2025 through March 2026 recorded multiple resident complaints and resident council concerns about not receiving baths or showers as expected, including reports from several residents that they had gone extended periods without bathing and that staff told them they were being skipped because other residents had waited longer or due to staffing issues. During a resident council interview, several residents reiterated that baths were not completed as scheduled and described waiting from eight days up to three weeks between baths, as well as equipment issues such as a broken chair that prevented bathing. Nursing staff, including an RN and a restorative aide, acknowledged receiving complaints that residents were not getting baths as scheduled and stated that residents sometimes went more than a week without a bath, and that missed baths could contribute to odors, dignity concerns, and skin conditions. The DON stated she expected residents to be bathed according to their care plan preferences and that refusals should be documented, but she was aware of prior grievances about missed baths. The facility’s bathing policy stated that residents have the right to choose the timing and frequency of bathing and required documentation of bathing activity or refusals and reapproach after refusals, but the documented patterns and interviews showed that these requirements were not consistently met.
Failure to Provide Planned Restorative Nursing Programs for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide ongoing restorative nursing programs as care planned and ordered for two cognitively intact residents with limited ROM and mobility. One resident, with Type 2 DM with diabetic neuropathy, an above-knee amputation, adjustment disorder with depressed mood, and stage 4 CKD requiring dialysis three times weekly, reported frustration that the fingers on her right hand were stiff and that she could no longer make a fist. She stated she felt weaker and believed she was not receiving the exercises she needed, explaining that she previously had exercises but no longer was brought for them. She reported that when she complained to therapy about not getting her exercises, she was told that restorative nursing aides were now responsible for providing them. Record review for this resident showed a physician note directing staff to encourage participation in restorative activities and a physician’s order for staff to encourage restorative activity three times weekly with a progress note to be completed on day shift when done. Her care plan included participation in restorative therapy with a goal to maintain current functional ability and interventions of AROM per therapy and nursing recommendations. Her MDS documented functional limitations in ROM in one upper and one lower extremity and indicated she received only two days of AROM restorative nursing programs in the seven-day look-back period. Restorative documentation from mid-December through late March showed that for lower extremity exercises she was documented as not available on multiple days, refused on several days, and not applicable on others, with only two days of restorative lower extremity exercises provided. For kinetic bike exercises over a three‑month period, she was documented as not available or refusing on multiple days, with several days marked not applicable, and only four days of kinetic bike restorative exercises completed. A second resident, who used a power wheelchair, had limited use of upper and lower extremities, and diagnoses including rheumatoid arthritis, polyneuropathy, and fractures of the right lower leg and foot, reported via an iPad translation device that she had participated in PT on admission and was discharged to a restorative program. She stated she was upset that she had not been receiving her exercise program, had complained to the DOR, and felt she was losing strength and her ability to stand and transfer. Her BIMS score indicated she was cognitively intact. Her MDS showed functional limitation in ROM in one lower extremity and no restorative nursing exercise programs received. Her care plan called for participation in a restorative therapy program to maintain functional abilities, with interventions including AROM, sitting exercises with a 3‑lb green TheraBand, trunk exercises x15 reps, and transfers involving standing with a walker up to 10 minutes. Restorative documentation from late January through late March showed multiple refusals and days marked not applicable, with no documentation that she received lower extremity exercises or stood with her walker for ten minutes during that period. Interviews with therapy staff and restorative aides revealed that therapy had provided written restorative recommendations on transfer forms, and the DON was responsible for setting up the programs. The therapy team expected two restorative aides to complete the recommended exercise programs, including upper and lower extremity exercises three to six times per week for the first resident (arm bike, recumbent kinetic bike, 5‑lb weights, green bands) and a lower extremity program three to six times per week for the second resident (standing with walker for ten minutes, 3‑lb weights, green bands). One restorative aide reported that she and the other aide were responsible for restorative exercises for about 44 residents, each scheduled for 15 minutes daily, and that it was impossible to see all residents when only one aide was working. She stated some residents were prioritized because they were ready, independent in getting to the exercise room, and enjoyed exercising, while others known to refuse were deprioritized when staff were busy. She acknowledged not having completed restorative exercises with the first resident recently and not having done restorative exercises with the second resident in over a month. The other restorative aide confirmed workload challenges, restrictions on being alone with the first resident, difficulty coordinating use of the main therapy room and equipment, and uncertainty about when either resident last received restorative exercises. The DON and regional nurse consultant confirmed that the facility’s policy defined restorative nursing as interventions to promote optimal functioning, that residents with written programs were expected to receive at least 15 minutes per day, and that the first resident had received only seven days of restorative exercises since mid‑December while the second resident appeared to have received none since late January, and they were unaware of the residents’ concerns.
Inaccurate MDS Coding for PASRR, Insulin, and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for PASRR status, insulin administration, and psychotropic medication use for five sampled residents. Review of the records showed that two residents had approved PASRR Level II determinations, but their comprehensive MDS assessments indicated they did not have PASRR Level II status. One of these residents had diagnoses of depression, bipolar disorder with psychotic features, and anxiety, and the other had diagnoses of major depressive disorder and generalized anxiety disorder with a physician’s order for sertraline. Social services staff stated they entered PASRR information on the MDS and should have indicated that both residents had PASRR Level II status, and the DON stated she expected the MDS to reflect PASRR Level II when present. The facility also inaccurately coded insulin use for a resident who was receiving both long-acting and short-acting insulin. The resident was observed and documented as receiving glargine once daily and aspart three times daily with meals for diabetes, and the resident’s BIMS score indicated moderately impaired cognition. Despite this, the quarterly MDS coded that no insulin injections had been received during the seven-day look-back period. The MDS RN verified that the resident had been administered insulin four times a day since the physician’s order and that the MDS entry was inaccurate. In addition, the facility inaccurately coded psychotropic medication use for two residents. One resident had orders for trazodone and escitalopram, but the MDS coded that an anti-anxiety medication had been received during the look-back period even though no anti-anxiety medication was ordered. Another resident had a physician’s order for Rexulti for behaviors related to Alzheimer’s disease, but two quarterly MDS assessments coded that no antipsychotic medication had been received. The MDS RN verified both errors, and the DON stated she expected the residents’ MDS assessments to be coded accurately. The facility policy and the CMS RAI Manual stated that PASRR Level II status, insulin use, and psychotropic medications must be coded according to the resident’s actual status and medication classification.
Baseline care plans not completed or reviewed within required timeframe
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for three sampled residents and failed to ensure that baseline care plans were reviewed with, and a copy offered to, seven sampled newly admitted residents within 48 hours of admission. Review of records showed that resident 2’s baseline care plan was not locked as completed until 7 days after admission, resident 6’s baseline care plan was reviewed 5 days after admission, and resident 98’s baseline care plan was reviewed 5 days after admission. Resident 44’s baseline care plan was reviewed and a copy provided at a care conference held 4 days after admission, and resident 30’s baseline care plan was completed but there was no documentation that it was offered or reviewed with her after admission. Resident 36 stated he did not recall anyone reviewing his baseline care plan with him or offering him a copy after admission, and the record showed his baseline care plan was documented as reviewed with the resident or representative on a date after admission, with no documentation that a copy was offered. Resident 61’s record showed his baseline care plan was reviewed with the resident or representative, but there was no documentation that a copy was offered. Resident 44 stated he was upset about not receiving his nitroglycerin patch heart medication when ordered and said he spent the day and night worrying that something terrible would happen to him because he was not given that medication. He also stated that a care meeting was held during his second week at the facility and that he was provided a copy of his care plan then. Interviews with staff showed that the LPN/unit manager expected baseline care plans to be initiated on the day of admission and reviewed at the 48-hour care conference, and the SSD was responsible for printing the care plan, providing it to the resident, and scheduling the care conference. The SSD stated that when residents admitted on Thursday or Friday, the conference was scheduled for Monday or Tuesday and was considered the 48-hour care conference, and she confirmed that resident 44 received his baseline care plan 4 days after admission, not within 48 hours. The DON and administrator both stated that residents were to be provided a copy of their baseline care plans and that the plans were to be reviewed with the resident or representative within 48 hours of admission. The facility policy stated that the baseline care plan is started on the first day of admission and completed no later than 48 hours after admission, and that during the care conference the care plan is reviewed with the resident and/or representative and may be printed and signed.
Failure to Maintain Resident Dignity, Hygiene, and Privacy During Personal Care
Penalty
Summary
The deficiency involves failures to maintain resident dignity, hygiene, and privacy for multiple residents who were dependent on staff for personal care. One resident with severely impaired cognition, depression, and senile degeneration of the brain was dependent on staff for dressing, personal hygiene, and transfers with a full body lift. Her care plan required staff to use yes/no questions and clear explanations due to her communication difficulties. Her family reported concerns that she was not being changed regularly, was left in bed in her nightgown until mid-afternoon, and was not assisted out of bed to the dining room for meals. The family also reported finding dried juice on the resident’s stomach and bed sheets on consecutive days, indicating the linens had not been changed, and later finding the resident in bed around mid-afternoon in pajamas with food on her face and clothing. During the survey, the resident was observed in the afternoon with a dried green substance on her nose that remained there over an extended period, despite her dependence on staff for hygiene. Another resident with severely impaired cognition, unclear speech at times, and dependence on staff for personal and oral hygiene and dressing was repeatedly observed with soiled clothing and unclean hands and face. He was first seen lying in bed wearing a white shirt with multiple brown discolorations on the chest and arms. Later the same day, he was observed in the dining room wearing the same soiled shirt and spilling coffee repeatedly onto his clothing protector and shirt without staff offering assistance or interventions to prevent further spillage. That afternoon, he was again observed in bed wearing the same dirty shirt with food in his beard and stated he would have liked staff to change his shirt and that he had trouble with spilling food and drinks and wanted more assistance with eating and drinking. On another day, he was observed twice in the hallway with food in his beard and a thick orange substance on his fingers around his fingernails, as well as food on his shirt, with no indication in the record that he had refused clothing changes or hand and face washing. A third resident with severely impaired cognition, depression, anxiety, and a care plan noting severe mental illness with risk for abuse and neglect did not receive adequate privacy during incontinence care. Two CNAs assisted this resident in his shared room by placing a gait belt, helping him stand at the sink, lowering his pants, removing his incontinence brief, cleaning his private areas, and applying a new brief while his roommate was in bed. The privacy curtain was not pulled far enough to prevent the roommate from seeing the resident, and the window blinds were open, leaving him exposed during personal care. Staff interviews confirmed that residents’ clothing should be changed when soiled, faces and hands washed after meals or when soiled, refusals documented, and privacy ensured by closing doors, blinds, and curtains during personal care. The observations and interviews showed that these expectations and the facility’s dignity and privacy policy were not followed for these residents.
Resident Left in Dining Room for Extended Period Without Required Care
Penalty
Summary
The deficiency involves a resident with severe cognitive impairment who was left in the dining room for approximately ten hours without receiving care as outlined in his care plan. According to the SD DOH Facility Reported Incident, the resident was brought to the dining room at around 8:30 a.m. and was not taken back to his room until 6:31 p.m. that day. During this period, the resident did not receive identified interventions to meet his care needs from the CNA and LPN assigned to him. The facility’s investigation determined that the resident was neglected because his care plan was not followed and necessary care was not provided for an extended period. The resident’s medical record showed he had a BIMS score of 1, indicating severely impaired cognition, and diagnoses of metabolic encephalopathy and dementia. His care plan documented that he was at risk for skin impairment due to a history of stage II pressure ulcers, required repositioning every two hours and as needed, had a urinary catheter with urine output to be documented each shift, and required substantial assistance with toileting hygiene every two to three hours, transferring, and wheelchair mobility. He was also identified as being at risk for falls and was to be treated with respect and dignity and to reside free of mistreatment. Despite these documented needs, the resident remained in the dining room for about ten hours without the planned care being provided. The FRI report noted that the resident had a urinary catheter, could move and readjust himself in his wheelchair, was forgetful, and needed staff assistance with using the bathroom. Although his skin assessment after the incident did not show skin breakdown related to the event and he was not incontinent of bowels, the facility’s investigation concluded that the failure of the assigned CNA to follow the care plan and provide care during the prolonged period in the dining room constituted neglect. Interviews with the DON confirmed that the facility’s investigation found the resident had been neglected by staff on that day because his care needs, as specified in his care plan, were not met for approximately ten hours.
Failure to Follow Care Plan Requiring Two Caregivers During Resident Care
Penalty
Summary
Non-compliance at F684 occurred when a resident who was care planned to receive all care from two caregivers at all times was assisted by a single CNA. The resident had a documented history of making allegations of staff being rough and was identified in the care plan as requiring "cares in pairs" with two caregivers present to address her needs and observe the entire care session. Despite this, the CNA entered the resident’s room alone and began providing care without a second staff member present, contrary to the resident’s care plan and the facility’s expectations. The resident’s care plan, initiated on 10/28/22, identified manipulative behavior and alleged mistreatment as focus areas, noting that the resident might voice allegations of mistreatment or exploitation by caregivers, related to feelings of loss of independence, and might use abusive language. Interventions included assuring the resident she was safe and secure, providing two caregivers to address her needs and observe the entire session, having supervisory personnel observe care delivery as much as possible, and offering staff of certain racial backgrounds when able, based on the resident’s stated preferences and history of accusations. On the date of the incident, the resident reported to an LPN that the CNA had been rough with her during care that was provided without a second caregiver present. Staff interviews confirmed that the resident was known to make accusations, tell inconsistent stories, and sometimes scream even before being touched, and that she was to always receive care with two staff present because of these behaviors and prior allegations. On the day of the incident, staff on duty reported hearing the resident screaming after the CNA entered the room and began helping her, then left to get a second person to assist. The CNA acknowledged going into the room alone and assisting the resident with care, thereby not following the resident’s care plan requirement for two caregivers to be present during care, which led to the cited deficiency under F684.
Inconsistent Code Status Documentation
Penalty
Summary
The provider failed to ensure that the code status for two sampled residents was currently and accurately documented in the electronic medical record (EMR). Resident 25’s EMR banner listed her as Full Code with no intubation, and there was a physician order matching that status, but her signed code status form showed she chose Do Not Resuscitate (DNR). Her pocket care plan also listed her as Full Code, and there were no other signed code status forms in her EMR. Resident 2’s EMR banner listed her as DNR: OK to intubate, and there was a physician order with that same designation. However, her signed Resuscitation Designation Order indicated she wanted to be DNR, with no documentation on that form showing she wished to be intubated. Her pocket care plan listed her as Full Code. Interviews with CNA/CMA V, LPN O, DON B, and the administrator confirmed that the residents’ code statuses were inconsistent across the EMR banner, signed forms, and pocket care plans, and that these discrepancies created a risk that the residents’ wishes may not be followed if they had a medical emergency and were unresponsive.
Food Handling and Hand Hygiene Failures During Meal Service
Penalty
Summary
The provider failed to follow standard food safety practices during meal service in the Central dining room. During observation, one dietary aide touched her face, hair, and pants and did not wash or sanitize her hands before handling resident food, including placing covers on plates, moving room trays, serving plates of food, and applying butter to a resident’s bread with bare hands. She also washed her hands for only about four seconds before wiping them on paper towels and then on the back of her pants before serving another resident’s food. The observation also showed the dietary aide dropped a chocolate milk lid on the floor and then put it back on the milk container. In interview, she stated she was supposed to sanitize her hands after every three resident plates, before placing room trays on the cart, after touching a resident, her face, hair, or pants, and to wash her hands and put on gloves before touching resident food, with handwashing for about 20 seconds. The dietary manager confirmed these expectations and stated that if a milk lid fell on the floor, it was to be thrown away. The facility’s hand hygiene policy stated staff are to wash hands for at least 20 seconds and before and after handling food and direct resident contact.
Failure to Follow Hand Hygiene, Glove Use, and Disinfectant Contact Time
Penalty
Summary
Staff failed to follow standard infection control practices during housekeeping activities in resident rooms. During an observation of housekeeper HH cleaning a resident room, she put on gloves without performing hand hygiene, removed garbage bags from the room, replaced them with new bags, and continued handling cleaning supplies and equipment with the same gloves on without removing them or performing hand hygiene between tasks. She sprayed and wiped a countertop, cleaned dried mud from the floor beside the resident's bed, swept the room, dumped dirt into the housekeeping cart, and mopped the room before removing her gloves and using alcohol-based hand sanitizer at the end. During another observation, housekeeper DD entered a resident room wearing gloves without first performing hand hygiene and used Multi-Surface Peroxide cleaner on a recliner, cabinet, and bed, wiping each surface immediately after spraying. She then removed her gloves and performed hand hygiene after leaving the room. DD stated she used the cleaner on hard surfaces in resident rooms and would let it remain on a surface only if it was visibly soiled before wiping it off; if the area was not visibly soiled, she sprayed and wiped it off immediately. The label on the Multi-Surface Peroxide cleaner directed staff to spray on hard surfaces, wait 1 to 2 minutes, agitate if necessary, and wipe dry. An interview with housekeeping staff showed one housekeeper did not know whether the cleaner had a contact time for disinfection. The facility's hand hygiene policy stated hand hygiene was required before donning gloves and after removing gloves, and that gloves do not replace hand hygiene. The administrator stated hand hygiene and glove use were standard between departments and that staff were expected to follow the recommended contact time for each chemical used.
Unauthorized Application of Nair to Perineal Area Resulting in Chemical Burn
Penalty
Summary
The deficiency involves a CNA applying Nair, a chemical hair removal cream, to a resident’s perineal area without a physician’s order, resulting in a chemical skin burn. The CNA reported that the cream was present in the resident’s room and that the resident requested its use during a shower. The product was applied as a personal hygiene measure despite facility expectations, as described by multiple LPNs and the unit manager, that any over-the-counter product such as Nair requires a physician’s order and must be stored securely. The CNA’s actions occurred outside the scope of delegated tasks, as other staff indicated that chemical hygiene products should be applied by a nurse and that cognitively impaired residents are not reliable sources for requesting such products without an order. The resident involved had multiple significant medical diagnoses, including multiple sclerosis, cerebrovascular disease with hemiplegia and hemiparesis, DVT, and epilepsy, and was identified as a long-term resident requiring extensive assistance with care. A recent BIMS score of 5 indicated severely impaired cognition, and she was dependent on staff for all care, including the ability to remove products such as Nair from her skin. Following the application of the cream, an LPN performing a regular wound treatment the next day observed that the resident’s peri area was red and sore. The LPN initially thought the area resembled razor burn and then confirmed with the CNA that the area had not been shaved but had been treated with Nair at the resident’s request. Subsequent documentation and hospital records described the resident’s peri area as pink and appearing healed on a weekly skin assessment, but the hospital later reported that she had chemical burns on her bilateral thighs and labia due to Nair being left on too long, and that she developed cellulitis from the burn. The resident’s mother, who was her legal guardian, stated she had purchased the Nair for use on the resident’s legs and that family members had applied it to the legs, not the peri area. She learned from facility staff that the cream had been applied to the peri area by staff and that this resulted in a chemical burn. The resident herself reported not knowing what Nair was, did not know who applied it to her peri area, and stated that the staff member who applied it did not provide additional care that day. The facility’s policies and staff interviews confirmed that over-the-counter products like Nair required a physician’s order, secure storage, and appropriate delegation, which did not occur in this incident, leading to the resident receiving treatment without an order and sustaining a chemical burn.
Failure to Timely Assess, Treat, and Prevent Worsening Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident admitted with an existing stage II coccyx pressure ulcer and multiple areas of skin redness. On admission from the hospital, transfer orders specified detailed skin breakdown risk interventions, including Q2H repositioning, heel elevation, moisture protection, use of a lift pad, and specialty bed if indicated. The admission skin assessment documented a stage II coccyx ulcer with specific measurements and no redness to ankles, elbows, or hips, and the Braden Scale indicated high risk for pressure ulcer development. However, although a physician’s order for heel boots while in bed was dated the day of admission, it was not set to start until several days later, and an air mattress was not ordered until weeks after admission. The facility’s own policy required a baseline skin assessment on admission, immediate prevention plans when potential areas were identified, and a wound assessment when a pressure injury was identified, but the wound nurse did not complete an initial wound assessment until eight days after admission. In the days following admission, there were significant gaps in monitoring, documentation, and implementation of wound care and preventive interventions. A family member reported that a nurse was unaware the resident had bed sores, that the wound nurse was on vacation, and that dressings placed on the buttocks remained unchanged for nearly two weeks. On 1/6, an LPN, prompted by the family, assessed the resident and found Mepilex dressings on the hips, right ankle, and coccyx, with an open area on the coccyx and redness on the right outer ankle and elbows; the removed dressings were dated from the admission date. At that time, there were no wound treatment orders in the EMR, no scheduled skin evaluation, and no air mattress, wheelchair cushion, or Prevalon boots in use, despite the resident’s high risk and existing wound. Another LPN completed a skin assessment on 1/7 after the family again raised concerns, noting an open coccyx area with slough and red areas on hips, ankles, and elbows, but did not measure the wound, relying instead on the wound nurse’s future weekly rounds. The order for Mepilex dressing changes every three days did not begin until eight days after admission. When the wound nurse finally documented the coccyx wound on 1/8, it was staged as a stage III pressure ulcer with slough and maceration of surrounding tissue, and subsequent documentation showed inconsistent and incomplete assessment of additional pressure areas, including the right outer ankle, which was later identified as a pressure ulcer without measurements or full description. Physician orders for Arginaid to support wound healing were not attempted to be administered until several days after the order date, and a documented daily Santyl dressing order was not recorded as completed on at least one scheduled day. Observations in early February showed the resident thin and frail, with an air mattress in place and Prevalon boots sometimes off, heels resting on the mattress or recliner footrest, and periods in a recliner without a seat cushion. Interviews with nursing leadership confirmed that the wound nurse did not evaluate or provide preventive interventions or treatments for the resident’s wounds between admission and 1/8, that the care plan was not updated with wound-related interventions at admission, that there was no skin assessment or evaluation policy beyond the general pressure injury prevention program, and that delays in pressure reduction interventions and treatment could have delayed healing of the coccyx pressure ulcer.
Failure to Follow Two-Person Transfer Care Plan Resulting in Resident Injury
Penalty
Summary
The deficiency involves a failure to ensure a resident was transferred according to the care plan, resulting in injury. A resident with intact cognition, muscular dystrophy, unsteadiness on her feet, and decreased mobility had a care plan dated 11/24/25 indicating she required extensive assistance of two staff members for transfers. On 1/15/26 at around 4:00 p.m., a CNA, who knew the resident required two-person assistance, attempted to transfer the resident alone. During this transfer, the resident’s left leg struck her wheelchair, causing two skin tears, and she later experienced increased pain in her left knee, for which an x-ray was obtained on 1/19/26. The CNA reported that she had previously transferred the resident alone without problems and described grabbing the resident under the armpits, lifting her from the wheelchair, and turning to place her on the bed. She realized the bed was not in a low position and could not lift the resident high enough, so she turned back to place the resident in the wheelchair. As the resident was set down, she began to slide out of the wheelchair and was lowered to the floor, during which her leg hit the wheelchair and the skin tears occurred. Other CNAs interviewed knew where to find resident care and transfer information. The facility’s CNA job description and care plan policy required CNAs to be knowledgeable of and follow individual care plans, and to provide care that maintains skin integrity and safeguards residents’ health, safety, and welfare.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
Two residents eloped from the facility on separate occasions by exiting through the front door without staff knowledge. In both incidents, the residents were mistaken for visitors by staff members, which allowed them to leave the premises unsupervised. The facility's front door alarm system was bypassed using an employee's badge, enabling the door to be opened without triggering an alert. In the first incident, a resident in a wheelchair independently left the facility when a visitor opened the front door, and was later found sitting outside alone. In the second incident, another resident, also in a wheelchair, exited the facility when two CNAs held the door open after their shift, not recognizing her as a resident or being aware of her elopement risk status. The first resident had a moderate cognitive impairment with a BIMS score of ten and diagnoses including hypertension, venous thrombosis, TIA, and tachycardia. Although his initial elopement risk evaluation determined he was not at risk, he was found outside alone and was unaware of his location or the events when interviewed. The second resident had a severely impaired cognition with a BIMS score of three, a history of wandering, and was identified as high risk for elopement. She was found outside with another resident who was permitted to go out alone, but she herself was not allowed to do so without staff supervision. She did not recall the incident during her interview but was aware that she needed staff accompaniment to go outside. Staff interviews revealed a lack of awareness regarding which residents were at risk for elopement, despite the existence of an elopement binder with photos and information at key locations in the facility. Some staff members, particularly newer employees, were not familiar with all residents or had forgotten about the elopement binder and its purpose. The front door's security system was compromised by staff badges, which allowed residents to exit undetected when accompanied by staff or visitors. These actions and inactions led to the failure to provide adequate supervision and prevent accident hazards, resulting in the deficiency.
Failure to Serve Food at Safe Temperature Results in Resident Injury
Penalty
Summary
A deficiency occurred when a staff member failed to serve food at a safe and appetizing temperature, as required by facility policy. Specifically, a cook served tomato soup at a temperature of 171 degrees Fahrenheit, which exceeded the facility's acceptable serving range of 140 to 165 degrees Fahrenheit for hot entrees. The soup had been cooked to 181 degrees and was plated at 171 degrees, without being cooled to the appropriate serving temperature prior to delivery to residents. As a result, a resident who was eating in his room accidentally spilled the hot soup on his chest and left arm. The resident experienced mild skin redness and stinging, though no blisters or significant pain were reported. The redness resolved within a short period, and the resident's skin remained intact. The incident occurred while the facility was serving meals in resident rooms due to a flu outbreak, which increased the time between plating and delivery, prompting staff to keep food at higher temperatures on the steam table. The resident had a history of hot liquid safety assessments, with interventions such as lidded cups and staff assistance being implemented and adjusted over time based on periodic reassessments. At the time of the incident, the resident was considered not at risk for hot liquid injuries, and the intervention for a lidded cup had been removed. The soup spill led to a reassessment and the reintroduction of safety interventions for hot liquids.
Failure to Adhere to Enhanced Barrier Precautions and Environmental Cleaning
Penalty
Summary
Staff failed to follow infection prevention practices related to the use of personal protective equipment (PPE) and cleaning of shared equipment for residents on enhanced barrier precautions (EBP). A certified nursing assistant (CNA) was observed transferring multiple residents using a mechanical lift without wearing a gown, despite clear signage and available PPE indicating that gown and glove use was required for residents on EBP. The CNA also failed to clean the lift after each resident use, as required by facility policy and confirmed by interviews with other staff members. Multiple residents on EBP, due to conditions such as wounds, feeding tubes, or multi-drug resistant organisms (MDROs), reported that staff typically wore gloves but not gowns during care and transfers. Additionally, the report documents that urinals without lids were used and left in resident rooms, and that a spill of urine on the floor in one resident's room was not cleaned for approximately two hours. The resident expressed concern about the unaddressed spill, and staff were unaware of the issue until it was brought to their attention. Observations confirmed the presence of urine on the floor, and urinals without lids were noted in the room. The infection preventionist and director of nursing confirmed that urinals should have lids unless otherwise care planned, and that environmental cleanliness is expected. Review of facility policies confirmed that EBP requires gown and glove use during high-contact care activities for residents with wounds, indwelling devices, or MDROs, and that shared equipment such as lifts must be cleaned after each use. The observed and reported failures to adhere to these policies resulted in deficiencies in infection prevention and environmental cleanliness for multiple residents.
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 observations and record reviews that indicated lapses in pressure ulcer management and prevention protocols. The report notes that the facility did not consistently follow established procedures for monitoring, treating, and documenting pressure ulcers, which contributed to the occurrence and progression of these wounds among residents. There is no mention of specific residents, their medical histories, or the exact circumstances of the pressure ulcer development, but the deficiency centers on the facility's failure to adhere to required standards for pressure ulcer care and prevention.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Medication Administration Error Due to Failure to Follow Identification Protocols
Penalty
Summary
A licensed practical nurse (LPN) failed to follow professional nursing standards of practice regarding medication administration by giving one resident another resident's medications. Specifically, the LPN administered medications intended for a different resident, which included Zolpidem, to which the recipient had an allergy, and Eliquis, a blood thinner not prescribed for the recipient. The error occurred after the LPN became distracted by a resident in the hallway, stepped away from the medication cart, and upon returning, mistakenly gave the wrong medications. The LPN had labeled the medication cups with residents' first names, which were similar, and the residents' rooms were adjacent to each other, contributing to the confusion. The facility's policy outlined the five rights of medication administration, and staff were educated on the six rights, but the LPN admitted to not following these protocols during the incident. Interviews with other nursing staff confirmed the expected procedures for resident identification, including using the electronic medical record (EMR) photo, verifying the resident's name and date of birth, and matching room numbers. Despite these established procedures, the LPN did not adhere to them, resulting in the medication error. No adverse reactions were observed in the resident who received the incorrect medications.
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 Follow Professional Standards in Medication Administration and Weight Monitoring
Penalty
Summary
The provider failed to ensure that professional standards were met in the administration of PRN controlled pain medications for two residents. For both residents, the medication administration records showed that oxycodone was given at intervals shorter than the four hours specified in the physician's orders. In several instances, doses were administered less than one, two, or three hours apart, contrary to the prescribed schedule. Interviews with the director of nursing revealed uncertainty about the facility's policy regarding early administration of PRN medications, and a review of the facility's policy confirmed that medications were to be administered according to prescriber orders and the six rights of medication administration. Additionally, the provider did not follow professional standards in monitoring and responding to significant weight changes for a resident with congestive heart failure and a recent hip replacement. The resident experienced a documented weight gain of twelve pounds over two days, but there was no evidence that the resident was re-weighed to confirm the accuracy of the measurements, nor was there documentation that the charge nurse acknowledged the weight gain or that the physician was notified, as required by facility policy. Interviews with facility leadership confirmed that the policy was not followed in this instance.
Diversion of Controlled Medications by RN
Penalty
Summary
A registered nurse (RN) diverted controlled pain medications prescribed to two residents, failing to protect their belongings and medications as required. The RN, who was enrolled in a health professional assistance program, admitted to diverting oxycodone from the residents, stating that he took the PRN pain medication when the residents did not request it. The facility's medication administration records (MAR) and narcotic sign-out sheets revealed discrepancies, such as pills being signed out but not documented as administered, and vice versa. The RN was unable to specify the exact amount of medication diverted. The residents involved included one who was cognitively intact and reported no recollection of missing pain medication and felt their pain was adequately controlled, and another resident with severe cognitive impairment who also did not recall missing medication and felt their pain was managed. Review of the MARs showed that the RN documented multiple administrations of oxycodone to both residents, but further review of the narcotic sign-out sheets and MARs identified inconsistencies in documentation and pill counts. The facility's process for reviewing narcotic administration relied on matching pill counts on sign-out sheets with the documented remaining pills, without cross-referencing the MAR for actual administration. This lack of thorough review allowed the diversion to go undetected until the RN's behavior raised concerns, leading to a positive drug test and subsequent admission of diversion. The local police were notified and confirmed the RN's account matched the facility's findings.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The report highlights a significant deficiency in the facility's response to resident call lights, which has adversely affected the well-being of multiple residents. Observations and interviews revealed that residents experienced prolonged wait times for assistance, ranging from over 10 minutes to nearly three hours. This delay in response led to residents feeling frustrated, sad, and in some cases, resulted in incontinence and unmanaged pain. Residents expressed that the lack of timely assistance made them feel neglected and that their needs were not prioritized by the facility's management. Several residents, including those with cognitive impairments and physical limitations, reported specific instances where their call lights were not answered promptly. For example, one resident, who was paraplegic and required assistance for all transfers, reported waiting up to nearly two hours for help, which led to feelings of depression and frustration. Another resident, who experienced severe pain, had to wait for extended periods before receiving assistance, exacerbating their discomfort and distress. The report also noted that some staff would turn off call lights without providing the necessary assistance, further contributing to the residents' dissatisfaction and emotional distress. The facility's staffing levels were identified as a contributing factor to the delayed response times. Interviews with staff and residents indicated that the facility was often understaffed, with CNAs and nurses being responsible for more residents than they could adequately care for. The facility's director of nursing acknowledged the long response times and the challenges in maintaining adequate staffing levels. Despite the facility's policy requiring prompt response to call lights, the report found that the policy was not consistently followed, leading to ongoing issues with resident care and satisfaction.
Deficiencies in Medicare Notice Procedures
Penalty
Summary
The provider failed to ensure that the proper Medicare notices were filled out completely and in the required format for three sampled residents prior to their discharge from Medicare Part A skilled services. The review of the Entrance Conference Worksheets revealed that 50 residents were discharged from Medicare Part A skilled services, with 25 remaining in the facility and 25 discharged to home or a lesser care level. The deficiencies were identified in the handling of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) forms for residents 12, 13, and 354. Resident 354 did not receive a SNF ABN, and the NOMNC form provided lacked the provider's phone number, although it met the required two-day notice. Resident 12 received outdated SNF ABN and NOMNC forms, with the SNF ABN form missing a clear explanation of the care not covered and using technical jargon. Resident 13's SNF ABN form was also outdated, missing the provider's address and phone number, and the NOMNC form did not meet the required font size. Additionally, there was no confirmation that the annotated forms were mailed to the resident's representative after a phone call. Interviews with the administrator and MDS coordinators revealed a lack of policy regarding the notices and acknowledged the use of outdated forms. The MDS coordinators were responsible for providing the notices and had been trained on the Medicare notices. They were aware of the new NOMNC form but not the revised SNF ABN form until the day of the interview. The DON agreed that the descriptions and explanations on the forms needed to be easily understood, and the requirements and instructions for the forms should be followed.
Inadequate Infection Control for Respiratory Devices
Penalty
Summary
The facility failed to ensure proper infection control practices for six residents who required respiratory devices, leading to deficiencies in the cleaning, storage, and replacement of these devices. Observations revealed that oxygen concentrators, CPAP machines, and nebulizers were not maintained according to the facility's policies. For instance, Resident 54's oxygen nasal cannula was found lying on the floor without a storage bag, and the oxygen concentrator's filter was coated in dust. Additionally, there were no documented tasks in the medical records for cleaning or replacing the CPAP machine, mask, or tubing. Resident 62's oxygen concentrator filter was observed to contain dust and debris, and there was no documentation of cleaning or changing the oxygen tubing. Similarly, Resident 32's oxygen concentrator was running without a filter, and the nebulizer mask was not stored on a barrier to prevent contamination. The facility's staff, including the RN/unit manager and the assistant director of nursing, were unsure about the cleaning process for the oxygen concentrator filters, indicating a lack of clarity in responsibilities. Interviews with staff members, including the director of nursing and the infection preventionist, revealed inconsistencies in the understanding and execution of the facility's policies regarding the maintenance of respiratory equipment. The facility's policies required weekly replacement and cleaning of oxygen and nebulizer supplies, but these tasks were not consistently documented or performed. The failure to adhere to these policies resulted in the potential for contamination and infection among residents who relied on these respiratory devices.
Deficiencies in Refrigerator Temperature Monitoring and Food Safety
Penalty
Summary
The facility failed to maintain proper food safety standards in residents' personal refrigerators, as observed during a survey. The temperature logs for these refrigerators were incomplete, with many missing entries, and the recorded temperatures often exceeded the safe limit of 41°F, reaching up to 46°F. This failure to maintain appropriate temperatures could lead to the rapid growth of pathogenic microorganisms, posing a risk of foodborne illness. Additionally, several refrigerators lacked thermometers, making it difficult to monitor and ensure safe food storage conditions. The survey also revealed that food items in the residents' refrigerators were not consistently labeled or dated, which is crucial for tracking the freshness and safety of the food. In one instance, a resident's refrigerator contained an unlabeled bag of meat, which was identified by the resident as roast beef, but it lacked a use-by date. This lack of labeling and dating was a common issue across multiple residents' refrigerators, indicating a systemic problem in the facility's food safety practices. Interviews with facility staff, including the assistant director of nursing, director of nursing, and housekeeping staff, highlighted a lack of clarity and adherence to policies regarding refrigerator maintenance and temperature monitoring. Housekeeping staff were responsible for these tasks but were not fully aware of the correct temperature parameters or the importance of labeling and dating food items. The facility's policies required daily temperature checks and documentation, but these were not consistently followed, and there was no clear policy for cleaning residents' personal refrigerators.
System Breakdown in Infection Control and Resident Care
Penalty
Summary
The facility failed to ensure the quality of life and overall well-being of all 94 residents due to a widespread system breakdown in infection control practices, policies, and procedures. This included failures in enhanced barrier precautions, personal protective equipment usage, and distinguishing between air-borne and droplet precautions related to Covid. Additionally, there were deficiencies in hand hygiene and preventive maintenance of oxygen concentrators. The facility also did not develop and revise care plans in a timely manner, and services provided did not meet professional standards concerning medication administration and physician notifications. Furthermore, there was a lack of responsiveness to residents' concerns with call lights and staffing issues, negatively affecting the residents' psycho-social well-being.
Governing Body Fails to Ensure Quality Care for Residents
Penalty
Summary
The governing body of the facility failed to ensure the operation of the facility in a manner that guaranteed the overall quality of life and well-being for all 94 residents. During the survey conducted from February 25 to February 27 and March 4 to March 5, 2025, several deficient practices were identified. These deficiencies indicated that the provider had not been operating in a manner that ensured residents received quality care. Specific references were made to deficiencies under F582, F656, F658, F675, F695, F812, F835, and F880.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The report highlights several deficiencies in infection prevention and control practices within the facility. Observations revealed that staff failed to adhere to proper hand hygiene protocols during wound care procedures for two residents. Specifically, a Certified Nurse Practitioner (CNP) and a Licensed Practical Nurse (LPN) were observed not performing hand hygiene between glove changes while attending to residents with wounds. This lapse in protocol was acknowledged by the LPN, who admitted that the CNP missed opportunities for hand hygiene. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices in a timely manner. Several residents who required EBP due to wounds or urinary catheters did not have the necessary signage or personal protective equipment (PPE) in place until after surveyors began their inspection. This delay in implementing EBP was noted for multiple residents, some of whom had been admitted with conditions necessitating these precautions days before the survey. The report also identified issues with the labeling and storage of personal care items. Observations showed that personal care products, such as syringes, wound cleansers, and urinals, were not labeled with resident identifiers, leading to potential cross-contamination. Interviews with staff revealed a lack of a systematic process for replacing and labeling personal care items, contributing to the deficiencies noted in infection control practices.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to ensure that the care plans for two residents reflected their current individualized needs. Resident 54, who utilized oxygen and a CPAP machine, did not have his respiratory status, oxygen use, or CPAP use addressed in his care plan. Despite being admitted with these devices and having a physician's order for oxygen, there was no corresponding care plan focus area for his respiratory needs. Resident 64, who had an indwelling feeding tube removed, also had an outdated care plan. His care plan still included goals related to tube feeding, even though the tube had been removed a week prior. The removal of the tube was not communicated to the facility by the resident's family, and no new orders were provided upon his return to the facility. The care plan did not reflect the current status of his wound or dressing needs following the tube removal. Interviews with facility staff revealed that care plan updates were the responsibility of the interdisciplinary team, including unit managers and nurse managers, with assistance from MDS coordinators. The facility's policy required that care plans be initiated upon admission and maintained throughout the resident's stay, addressing both medical and personal care considerations. However, the care plans for these residents were not updated to reflect significant changes in their care needs.
Deficiencies in Medication Administration and Physician Notification
Penalty
Summary
The report identifies deficiencies in the administration of medication and physician notification for two residents in the facility. Resident 349, who has Parkinson's disease, experienced delays in receiving his carbidopa/levodopa medication on multiple occasions, which is critical for managing his symptoms. Additionally, there was a significant weight gain of 9.7 pounds over five days, yet there was no documentation indicating that the physician was notified of this change. The resident's spouse expressed concerns about the timing of medication administration and the noticeable swelling in the resident's legs, which was reported to the nursing staff but not adequately addressed. Resident 51, who has moderate cognitive impairment and is prescribed multiple medications for blood pressure management, had several instances of low blood pressure documented in her medical records. Despite these readings, there was no consistent documentation of physician notification or appropriate adjustments to her medication regimen. On one occasion, the metoprolol was administered despite a progress note indicating it should have been held due to low heart rate. The facility's policies require that medications be administered within a specific timeframe and that physicians be notified of any deviations, but these protocols were not consistently followed. Interviews with facility staff, including the DON and LPNs, revealed a lack of adherence to established procedures for monitoring and reporting significant changes in residents' conditions. The DON acknowledged the absence of documentation for physician notification and the discrepancies in medication administration records. The facility's policies on following physician orders and medication administration were not upheld, leading to the identified deficiencies in care for the residents involved.
Failure to Communicate Mattress Change with Hospice and Family
Penalty
Summary
The deficiency involved a failure to maintain open communication with a hospice service provider regarding the use of an overlay air mattress for a resident. The facility's policy preferred the use of alternating low air loss mattresses, but the resident had been using an overlay air mattress since September, as suggested by hospice. The facility attempted to switch the mattress without notifying the hospice or the resident's family, leading to discomfort and complaints from the resident and her daughter. On December 13, the facility's wound nurse discussed the mattress change with the resident, who agreed to try the new mattress. However, the following day, the resident experienced back and buttock pain, and her daughter reported that the mattress was flat, causing discomfort. The LPN discovered the mattress was set to static pressure instead of alternating pressure and adjusted it accordingly. Despite this, the resident's daughter remained upset about the mattress change. Interviews with staff revealed a lack of awareness and communication regarding the mattress change. The hospice nurse was unaware of the facility's policy against overlay air mattresses and had not been informed during care conferences. The facility's administrator admitted to knowing about the overlay air mattress since September but did not notify hospice until December 16. The resident's electronic medical record lacked documentation of communication with the resident's daughter or hospice about the mattress change.
Neglect of Resident Leads to Incontinence and Skin Sores
Penalty
Summary
The provider failed to protect a resident from neglect by a CNA who did not provide timely care, potentially resulting in the resident being incontinent for an unknown length of time and contributing to the development of two skin sores. The incident occurred during the night shift when CNA C, who was responsible for the resident, assumed that CNA D had provided care for the resident. However, CNA D did not assist with the resident, and camera footage confirmed that the resident was not checked on from 10:00 p.m. until 4:30 a.m. the following morning. The resident, who had a severe cognitive impairment with a BIMS score of 0, was found to have been incontinent with stool on her bed sheets and developed stage 2 pressure ulcers on both buttocks. Interviews with the facility's administrator, DON, and other CNAs revealed that it was an expectation for residents to be checked on and changed as necessary at least every two hours. However, there was no specific written policy enforcing this practice. The facility's investigation substantiated the neglect allegation against CNA C, who failed to ensure the resident's care needs were met. The facility's policies on toileting, incontinence, and CNA responsibilities emphasized the importance of attending to residents' needs to prevent neglect and maintain skin integrity.
Untrained RN Removes Tunneled Chest Catheter
Penalty
Summary
The deficiency involved a registered nurse (RN) at the facility who removed a tunneled chest catheter from a resident without having the appropriate training to perform such a task. The resident, who was receiving intravenous (IV) antibiotics for osteomyelitis, had a tunneled chest catheter placed in her right chest area. On the day of the incident, the RN removed the catheter, mistakenly believing it was a peripherally inserted central catheter (PICC) line, which he had an order to remove. The nurse practitioner was not notified of the mistake, and the resident still required approximately one month of IV antibiotic treatment. The facility's records and interviews revealed several gaps in training and policy. The RN involved had not received training on IV medication administration or the placement and removal of PICC lines or tunneled chest catheters during his employment. The facility lacked a policy for the removal of these lines, and the training packet provided to the RN did not cover these critical areas. Additionally, the assistant director of nursing (ADON) and the director of nursing (DON) were aware of the order to continue the resident's IV antibiotics, but there was a miscommunication regarding the discontinuation of the therapy. Interviews with other staff members, including a licensed practical nurse (LPN) and another RN, indicated a lack of education regarding IV antibiotic therapy and catheter management. The facility had not provided adequate training or competencies for the removal of PICC lines or tunneled chest catheters, and there was no evidence of a policy in place to guide staff in these procedures. The deficiency highlights a significant oversight in ensuring that nursing staff have the necessary competencies to safely care for residents with complex medical needs.
Inaccurate Care Plan for Tunneled Chest Catheter
Penalty
Summary
The facility failed to ensure that the care plan for a resident accurately reflected the current individualized treatment needs for a tunneled chest catheter. The resident's electronic medical record contained multiple references to the tunneled chest catheter as a PICC line, which was incorrect. The resident had a tunneled chest catheter placed in the hospital and was to receive IV antibiotics upon returning to the facility. However, the care plan did not reflect the presence of the tunneled chest catheter, did not specify the route of administration for the antibiotics, and did not address dressing changes for the insertion site. The physician's order summary included instructions for antibiotic administration and care related to a PICC line, but not for the tunneled chest catheter. Additionally, the resident's vascular access evaluations did not mention the presence of either a tunneled chest catheter or a PICC line. The resident, who had moderate cognitive impairment, was hospitalized at the time of the report. The facility's care plans policy emphasized individualized, resident-centered care planning, but the care plan in question did not align with the resident's current medical needs.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident was admitted on a Friday afternoon, and the care plan was not initiated until five days later. During this period, the resident experienced severe pain throughout the weekend, and there were reports of inadequate dressing changes for leg wounds, leading to drainage collecting on the floor. The facility's policy mandates that a baseline care plan be completed within 48 hours to guide direct caregivers, but this was not adhered to in this case. Interviews with staff, including the DON and an LPN, confirmed that the admission care plan should have been completed within the specified timeframe. However, the LPN could not provide a copy of the daily care sheet for the resident, which would have offered a brief care summary. The facility's policy emphasizes the importance of initiating a resident-centered care plan upon admission to ensure optimal quality of life, but this was not executed, resulting in the resident's unmet care needs and discomfort.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The provider failed to implement pressure ulcer prevention interventions for a resident, leading to the development and worsening of pressure ulcers. The resident, who had a history of wounds, was admitted to the facility with a stage 3 pressure ulcer that had healed but later reopened. Observations revealed that the resident was often found lying on her back without repositioning interventions documented in her care plan. Despite having heel protectors ordered, the resident initially refused to wear them, and her care plan did not include repositioning as a preventive measure. Interviews with staff and family members highlighted several issues contributing to the deficiency. The resident experienced pain and discomfort, which led to her refusal of repositioning and physical therapy. The family reported that the resident had been left in soiled diapers for extended periods and that call light responses were delayed, sometimes taking up to an hour. The resident's family also noted that she had been placed on hospice care, and her pain medication was being adjusted, which affected her alertness and ability to participate in her care. The facility's documentation and care planning were inadequate in addressing the resident's needs. The care plan lacked specific interventions for repositioning, and there was no evidence of collaboration between RNs and LPNs for skin assessments. The resident's wounds were facility-acquired, with the sacrum and buttocks wound worsening from a healed state to a stage 3 pressure ulcer. The right heel wound also worsened, indicating a lack of effective preventive measures and timely interventions.
Medication Administration Errors in LTC Facility
Penalty
Summary
The report identifies significant medication errors involving two residents at the facility. Resident 2, who had undergone a lung transplant, did not receive her prescribed immunosuppressant medication, Everolimus, as ordered by her physician. The medication was not ordered in a timely manner, leading to missed doses. Interviews with the RN unit manager and the DON revealed awareness of the missed doses and a transcription error in the electronic medical record, which contributed to the medication not being administered correctly. The resident was unaware of the missed doses, and the facility's medication administration records showed multiple instances where the medication was not given or only partially administered. Resident 1 had an order for Lorazepam to be administered intramuscularly as needed for violent muscle twitching and seizures. However, there were documented episodes where the medication was not administered despite the presence of symptoms that warranted its use. The DON confirmed that the medication should have been given during these episodes, indicating a failure in following the prescribed medication orders. Additionally, Resident 5 did not receive his prescribed insulin and other medications on several occasions. An anonymous complaint and interviews revealed that a nurse was uncomfortable administering insulin outside the prescribed time and was unable to monitor the resident adequately. The resident reported instances of not receiving his medications and expressed concerns about his blood glucose levels. The facility's records corroborated these claims, showing missed medication administrations without proper documentation or notification to the provider. The DON acknowledged the issue and noted that the nurse responsible had resigned, but the lack of documentation and communication regarding missed doses was evident.
Deficiency in Serving Food at Safe Temperatures
Penalty
Summary
The provider failed to ensure that room trays were served at a satisfactory temperature for two of three sampled residents. Observations and interviews revealed that food items such as fried eggs and cheeseburgers were left on the counter for extended periods before being served, resulting in them being delivered cold to residents' rooms. Resident 4 reported receiving cold breakfast on multiple occasions, despite having discussed the issue with the dietary manager. During an observation, Cook U was seen reheating food items without checking their temperatures before delivery, leading to inadequate reheating initially. Resident 6 also reported receiving cold food, attributing it to room trays being served after other residents in the dining room. The dietary manager acknowledged the issue and stated that various methods had been tried to keep food warm, with staff being educated on proper food temperatures. However, the problem persisted, as evidenced by resident council meeting minutes documenting food temperature issues in May and June, with no follow-up documentation in July. The facility's food temperature policy required reheating food to specific temperatures to ensure safety and palatability, but this was not consistently followed. The administrator and dietary manager were aware of the ongoing issues and had conducted audits and staff education, but the deficiency remained unresolved at the time of the report.
Sanitation and Food Storage Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The provider failed to maintain a clean and sanitary foodservice environment in the main kitchen and two kitchenettes, as well as implement safe food storage practices. Observations revealed that the overhead ventilation hood panels were covered in grease and dust, and there was a pungent smell coming from the dirty dish room. The dirty dish room had dried food splatters on the ceiling, fruit flies, a leaking sink, standing water, and mold-like substances on the walls. The dishwasher had a gray sludge buildup, and the chemical storage closet had standing water and a warped door due to water damage. In the walk-in cooler, the floor was caked with a black substance, and the condenser was dripping water onto food items. The walk-in freezer floor was littered with food debris and ice. In the [NAME] kitchenette, there were unlabeled and undated food items in the refrigerator, a flying insect in the supplement refrigerator, and water damage with black stains under the sink. The drawers and cupboards were filled with crumbs, dust, and dirt. The East kitchenette was in a similar state, with crumbs and dried food splatters in the cupboards. The dietary manager indicated that staff were supposed to clean the kitchenettes daily, but was unaware of the current state of cleanliness. Interviews with the dietary manager and administrator revealed that cleaning tasks were assigned and documented daily, but the manager admitted to possibly missing some weeks. The dietary manager attributed the presence of insects to the hot weather and stated that trash was taken out multiple times to deter bugs. The leaking sink was due to a crack in the seam, and the maintenance department was informed. Review of cleaning checklists and policies showed that tasks were signed off as completed, but the actual state of cleanliness did not align with the documented tasks.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The deficiency involved a failure to honor a resident's right to refuse a shower and to follow her care plan preferences. On the morning of the incident, a certified nurse aide (CNA) who was unfamiliar with the residents and their care plans was assigned to assist with showers in the rehabilitation unit. The CNA entered the resident's room early in the morning, waking her up and insisting she take a shower due to incontinence. Despite the resident's refusal and preference for showering later in the day, the CNA proceeded to assist her with the shower, leading to the resident feeling manhandled and expressing anger and mistrust. The resident reported that the CNA was rough, grabbing her by the arms and forcing her into a shower chair. The resident expressed her discomfort and anger to a physical therapist and her son, who then informed the facility's management. Interviews with other staff members revealed that the CNA was not briefed on the resident's care plan, which specified her preference for evening showers. The CNA's actions were not aligned with the resident's care plan, which contributed to the resident's distress. The incident highlighted a breakdown in communication and adherence to care plans, as the CNA was not informed of the resident's preferences or care needs. The resident's care plan indicated she required assistance with activities of daily living, including showering in the evening, which was not followed. The lack of proper briefing and understanding of the resident's care plan led to the incident, resulting in a deficiency citation for failing to honor the resident's rights.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The provider failed to immediately report allegations of abuse experienced by a resident, which delayed the reporting and investigation process. The incident involved a certified nurse aide (CNA) who was reported to have been rough with a resident on the morning of 5/27/24. The resident reported that the CNA forced her to wake up early, demanded she take a shower due to incontinence, and physically grabbed her by the arms and pushed her into a chair. This incident was not immediately reported to the administrator or designee, which is a requirement for handling such allegations. The administrator became aware of the situation through a grievance form on 5/28/24, a day after the incident occurred. Upon learning of the allegations, the administrator took steps to address the situation, including suspending the CNA and initiating an investigation. However, the initial failure to report the allegations immediately constituted non-compliance with the requirement to report suspected abuse promptly, as confirmed during the survey conducted from 6/19/24 to 6/20/24.
Communication of Physician's Orders
Penalty
Summary
Substantial compliance was confirmed after a phone interview with a hospice liaison. It was found that the numbers for three of the nurse's stations were provided to the hospice provider for faxing physician's orders, which included new medication orders. This indicates that the facility ensured proper communication channels for receiving critical medical information, thereby addressing the deficiency related to ensuring that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well-being.
Failure to Ensure Hot Liquid Safety
Penalty
Summary
The provider failed to ensure adequate supervision and safety measures to prevent hot liquid burns for residents. On 3/4/24, a resident in a wheelchair filled a personal plastic cup with hot water from a dispenser in the central dining room. The cup melted and spilled hot water onto her inner thighs, causing a burn. The resident's Hot Liquids Safety Evaluation had been incorrectly documented, indicating she was not at risk, despite scoring a four, which should have necessitated staff assistance with hot liquids. The necessary interventions were not added to her care plan until after the incident occurred. Another resident was observed independently filling an insulated cup with hot coffee and transporting it in her wheelchair without staff assistance. This resident had not had a Hot Liquids Safety Evaluation completed in the last quarter, and her previous evaluation indicated she required staff assistance with hot liquids. The facility's policy required these evaluations to be completed on admission, quarterly, and with significant changes, but this was not adhered to. Interviews with staff revealed that the central dining room doors remained open all day, allowing residents to access hot beverages independently. The facility had issues with completing evaluations due to staffing challenges, including difficulties filling the MDS coordinator position. The administrator confirmed that the evaluations for both residents were documented incorrectly and that staff supervision should have been provided based on their evaluation scores.
Failure to Follow Pain Management Orders
Penalty
Summary
The provider failed to follow physician orders to provide pain medication before scheduled wound care for a resident. The resident, who had multiple diagnoses including Type 2 diabetes, chronic kidney disease, and a history of a genetic disorder causing skin blisters, frequently experienced severe pain. Despite physician orders for pain management, including tramadol and later oxycodone, the resident's pain was not consistently assessed or managed. Documentation showed that pain medication was often not administered before wound care, leading to the resident experiencing significant pain during dressing changes. The resident's pain was not adequately assessed or documented, and non-pharmacological interventions were not consistently utilized or recorded. The resident's electronic medical record (EMR) revealed multiple instances where pain ratings were either not obtained or documented only once per day. The Medication Administration Record (MAR) indicated that prescribed pain medications were not administered as ordered, and the Treatment Administration Record (TAR) showed that wound care was performed without the necessary pain management. Interviews with staff confirmed that the resident often refused medications and dressing changes due to pain, but there was insufficient documentation to support these refusals. The facility's pain management policy required comprehensive pain assessments and interventions, but these were not consistently followed. The failure to manage the resident's pain effectively led to the resident experiencing severe pain, crying out, and ultimately requesting to go to the emergency room. The resident was admitted to the hospital for acute encephalopathy and cellulitis and later discharged into hospice care, where he passed away. Interviews with the wound nurse and director of nursing confirmed that the required pain assessments and medication administration were not documented, and they could not provide evidence that the resident received pain medication before wound care. The facility's pain management policy outlined the necessary steps for managing pain, but these were not implemented as required, leading to the deficiency in care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
