Avera Bormann Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkston, South Dakota.
- Location
- 501 North 4th Street, Parkston, South Dakota 57366
- CMS Provider Number
- 43A137
- Inspections on file
- 22
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Avera Bormann Manor during CMS and state inspections, most recent first.
Surveyors identified that several residents were seated for meals but routinely served last at the request of nursing staff, causing them to wait while others ate, and one resident’s request for additional food (a cut-up apple) was delayed until after meal service and provided without acknowledgment. Call light records showed multiple residents experienced repeated response times exceeding 25–45 minutes, leading to episodes where residents remained in bowel movements or urine while waiting for assistance and one resident having to yell from the doorway for help. Residents reported feeling forgotten, disgusted, embarrassed, and frustrated by these delays, while CNAs and the DON described expected response times of 1–20 minutes, and the facility’s policy required prompt call light response, though completed audits were not acted upon.
Surveyors found that staff left cups containing multiple oral medications with two residents at the breakfast table and then left the area, allowing the residents to take the medications on their own, including one instance where a pill was dropped on the floor. Review of the EMR and staff interviews showed there were no physician orders authorizing these residents to self-administer their routine oral medications, even though each only had limited orders for self-administration of specific treatments (Kenalog paste and nebulizer therapy). Facility policies required an assessment and a physician order for self-administration to be in place before residents could self-administer medications, but this process was not followed in these cases.
A resident experienced a fall in their room and was found on the floor on their side with a walker nearby. A CNA summoned a total body mechanical lift and sling, and an RN assessed the resident, noting unequal leg length and recognizing a likely hip fracture. Despite the suspected injury and the resident’s pain, staff placed a sling under the resident, changed a soiled brief, and used the mechanical lift to transfer the resident onto a medical cart, with documentation failing to clearly describe the transfer process. The DON reported that using a total body lift after falls, even with suspected injuries, was the facility’s usual process, while another RN with ED experience stated she would instead immobilize the area using a backboard and noted that most staff did not know how or where to obtain such equipment. The facility cited a nursing skills text as its professional standard, but staff interviews and the handling of this event showed inconsistent understanding and application of safe transfer practices for suspected fractures.
A resident with paraplegia and fall risk precautions fell to the floor during a transfer from bed to wheelchair using a full body mechanical lift operated by two CNAs while a third CNA observed. Witnesses, including the resident and staff, reported hearing a snap before the resident’s leg, shoulder, and then entire body slipped from the sling, with only three of four sling straps found attached to the lift afterward and no damage to the sling itself. One CNA stated it appeared a black strap was not securely hooked, and the DON later observed that a bottom strap was not attached and assumed it had not been properly placed inside the lift hook. Although staff reported receiving mechanical lift education, at least one CNA had not completed the mechanical lift safety checklist competencies, despite facility policy requiring training on correct mechanical lift use.
A resident with high fall risk and severe cognitive impairment suffered a fall and serious injuries after using a lift chair without a documented safety assessment. The lift chair was found raised, and the resident was unable to recall the incident. Staff interviews and record reviews confirmed that required lift chair safety assessments were not completed prior to the incident, despite facility policy mandating such assessments before use.
A resident with severe cognitive impairment fell from a mechanical bath chair lift after refusing to wear a safety belt, and the CNA failed to ensure its use. The resident sustained multiple rib fractures and a pneumothorax, required hospitalization, was later placed on hospice, and subsequently died. The incident was attributed to inadequate supervision and failure to implement required safety precautions during bathing.
A resident was found with an audible chair alarm clipped to her shirt without proper assessment or documentation. The alarm was used to prevent her from getting up unassisted due to her fall risk, despite her ability to use a call light. Staff interviews revealed no formal assessment process before implementing the alarm, and the facility's policies on falls and restraints were not followed, leading to the inappropriate use of the alarm.
A resident with hand contractures was unable to use a standard call light, and staff failed to provide an accessible alternative for at least a month. Although the resident was eventually given a soft squeeze call light, it was not consistently placed within her reach, particularly when she was in a specialized wheelchair.
Two CNAs failed to properly apply a mechanical stand aide sling and used unsafe transfer techniques for a resident with late-stage dementia. They did not secure the sling before lifting the resident and used an unapproved method of tilting a Broda chair to transfer the resident. The facility lacked documentation of training for these procedures, and the care plan did not include instructions for the observed methods.
Two CNAs failed to follow infection control policies during a resident transfer, neglecting hand hygiene and mechanical lift disinfection. Despite an empty hand sanitizer dispenser, they donned gloves without washing hands and did not sanitize the lift after use. Interviews confirmed these actions did not meet facility standards.
A resident eloped from the facility without staff knowledge, despite functioning door alarms. The incident was not reported as an elopement because the resident remained on campus. The resident was found near a hospital entrance and was unharmed. The staff's lack of awareness about reporting requirements contributed to the deficiency.
Failure to Honor Resident Self-Determination and Timely Call Light Response
Penalty
Summary
The deficiency involves failure to honor residents’ rights to self-determination and a dignified existence during meal service and in response to call lights. Surveyors observed that three residents (6, 8, and 9) were seated in the dining room before other residents but were consistently served last at both breakfast and lunch. A CNA stated these residents were usually served last, and a food service worker reported that nursing staff had requested these residents be served last due to one resident’s high fall risk. Despite the Director of Food Services’ expectation that residents be served when seated, these three residents waited about 19 minutes for their lunch while other residents were already eating. Additionally, another resident (7) requested a cut-up apple during lunch; the cook deferred the request until after meal service and only provided the apple after a surveyor prompted a second time, placing the bowl in front of the resident without verbal acknowledgment. The deficiency also includes prolonged call light response times that resulted in negative outcomes for multiple residents. Call light logs over a several-day period showed repeated response times greater than 25 minutes for four residents (1, 2, 3, and 4), with some instances approaching or exceeding 45–50 minutes. One resident reported having to sit in soiled bowel movements for one to two hours after using her pendant or call light, stating that staff sometimes turned off the light and said they would return but did not. Another resident reported feeling he waited a long time for assistance, urinated on himself while waiting for help to the bathroom, and felt disgusted by being unable to get needed help in time. Further interviews confirmed that another resident frequently waited for his call light to be answered, was incontinent before staff arrived, and sometimes yelled from his doorway for help when his call light had been on for over 30 minutes, which he described as embarrassing. A fourth resident reported waiting 20 to 30 minutes for staff to assist him up for meals and stated that on one occasion he was left in his room at suppertime until staff had finished getting everyone out of the dining room before helping him, which he found frustrating. CNAs interviewed stated their expected call light response times ranged from 1 to 10 minutes, while the DON stated her expectation was that no call light should go unanswered for more than 20 minutes. The facility’s call light policy required prompt responses to resident requests, but the DON acknowledged that although call light audits were done once or twice monthly, nothing had been done with the completed audits.
Failure to Obtain Physician Orders Before Allowing Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and verify physician orders for self-administration of medications before leaving medications with residents at the dining table. Surveyors observed on multiple occasions that RNs left cups containing multiple oral medications with two residents during breakfast in the dining room and then left the area, allowing the residents to take the medications on their own. One observation showed a resident dropping a yellow pill on the floor and notifying a surveyor, who then alerted the RN. On another occasion, an RN instructed a resident that if he did not want his MiraLAX, he should leave it on the table, and the resident delayed taking his medications while engaging in other activities such as changing the TV channel. Review of the electronic medical records and interviews with nursing staff revealed that neither of the two residents had a physician’s order authorizing self-administration of their routine oral medications, despite one resident having an order only to self-administer Kenalog paste for oral sores and the other having an order only to self-administer/self-consume nebulizer treatments after setup. The facility’s policies on medication management and self-administration required that residents be assessed for clinical appropriateness and that a physician’s order for self-administration be obtained and entered into the EHR before allowing self-administration. Staff interviews confirmed that a self-administration assessment should be completed first, followed by obtaining a physician’s order, and that nurses should verify the presence of such an order before leaving medications with a resident, which did not occur for these two residents.
Improper Transfer After Fall With Suspected Hip Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed professional standards for safely transferring a resident after a fall with a suspected hip injury. A complaint intake review by the South Dakota Department of Health noted multiple areas of care, including falls, and subsequent investigation focused on one resident who fell in his room. A CNA reported seeing the resident walking alone, then hearing a noise and finding him on the floor lying on his right side with his walker nearby and the door partially open. The CNA called for a total body mechanical lift and sling to transfer the resident from the floor, and the RN on duty responded to the fall, performed a nursing assessment including vital signs, ROM, and pain assessment, and observed that the resident’s legs were different lengths, making it obvious to her that his hip was broken. Despite the suspected hip injury and the resident’s pain, staff proceeded to place a total body lift sling under him and used the mechanical lift to transfer him from the floor to a medical cart, also changing his soiled incontinence brief while he was in pain during sling placement. The RN later stated she did not remember how the transfer to the medical cart was done, and the electronic medical record and facility-reported incident did not clearly document how the resident was moved from the floor, although the incident report indicated he was assisted off the floor onto a medical cart by a total lift with multiple CNAs and RNs. Another RN described her own practice as completing assessments on the floor, gathering a total body lift and staff, and calling the physician before moving a resident with a suspected head, neck, or hip injury, but this was not the process followed in this case. Interviews with other staff revealed inconsistency and lack of clarity regarding appropriate transfer methods for residents with suspected fractures. The DON stated it was the facility’s process to lift residents with a total body lift even if a suspected injury was present, and identified a nursing skills text as the professional standard used by the facility. In contrast, an RN coordinator with ED experience stated she would not use a mechanical total body lift for a resident with a suspected hip injury, but would instead obtain a hard backboard from the ED and immobilize the injured area, and she would avoid changing a soiled brief unless enough staff were available to immobilize the area. She also reported that most staff did not know what to do or where to obtain a backboard, and she was unaware of any facility policy on transferring a resident with a hip injury. The referenced nursing skills guide included special considerations for maintaining protected straight alignment (logrolling) for certain clients with spinal injuries or surgery, underscoring that the facility’s actual practice in this incident did not align with the professional standards it cited.
Resident Fall from Mechanical Lift Due to Improper Sling Attachment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer using a full body mechanical lift, resulting in a resident falling from the lift to the floor. A cognitively intact resident with traumatic spinal cord dysfunction and paraplegia, who had documented fall risk precautions, was being transferred from bed to wheelchair by two CNAs using a full body mechanical lift and a medium sling, while a third CNA in training observed. During the transfer, multiple witnesses, including the resident and the CNAs, reported hearing a snap or pop sound, after which the resident’s leg, shoulder, and then the rest of his body slipped out of the sling and he fell, striking his hip, shoulder, and head. The resident reported that he believed a strap was not hooked to the lift, which he thought allowed him to slide out of the sling. CNA H, who was observing, stated it appeared that a black strap on the sling was not securely hooked and slipped off the lift. CNA I, who operated the lift, described that the lower sling strap from the left side of the resident’s body, which had been attached to the right side of the lift bar, came off, leading to the resident landing on his hip, shoulder, and then his head. After the fall, staff observed that only three of the four sling straps remained attached to the lift, with one lower strap not attached, and no tears or broken loops were found on the sling itself. Interviews revealed that CNA I and CNA J each checked different sides of the sling attachments before the transfer, and both stated they typically double-check sling straps prior to lifting. CNA I reported she had never had the mechanical lift safety checklist competencies completed for her, and CNA J was unsure if she had completed those competencies, although both had received some form of mechanical lift education. The DON stated her assumption was that the strap was not on the inside of the hook on the lift bar and confirmed that, upon entering the room after hearing a crash, she saw three straps still attached to the lift and one bottom strap not attached. The facility’s mechanical lifts policy required that nursing personnel receive annual in-services on correct lifting and transferring procedures, including the correct use of mechanical lifts, but the report documents that the specific safety checklist competencies for mechanical lift use had not been completed for at least one of the CNAs involved in the transfer.
Failure to Assess Lift Chair Safety for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, identified as having a high fall risk and severely impaired cognition, experienced an unwitnessed fall from a lift chair. The resident was found on the floor in front of the lift chair, which was raised all the way up. She sustained a large hematoma on her forehead, a skin tear and bruise on her right hand, and later complained of neck pain. Subsequent medical evaluation revealed acute nondisplaced fractures of the C2 vertebra, leading to hospitalization for observation, pain control, and a neurosurgery consult. Prior to the fall, no lift chair safety assessment had been documented for the resident, despite her high fall risk and cognitive impairment. The resident's medical record confirmed that she was admitted with these risk factors, and her fall risk assessments consistently identified her as high risk. The lift chair safety assessment was only completed after her return from the hospital, at which point it was determined she required total assistance to operate the lift chair. Interviews with facility staff, including the RN/MDS coordinator, DON, and administrator, confirmed that lift chair safety assessments had not been completed for any residents prior to the incident. The facility's policy required a lift chair safety assessment before use, but this was not followed, resulting in the resident's fall and subsequent injuries.
Failure to Ensure Use of Safety Belt on Mechanical Bath Chair Lift Resulting in Resident Injury and Death
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure the use of a safety belt for a resident with severe cognitive impairment during a whirlpool bath using a mechanical bath chair lift. The resident, who had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment, resisted wearing the safety belt. While the CNA turned to retrieve the resident's clothing, the resident fell from the chair, which was positioned approximately 25 to 30 inches high. The fall resulted in a left forehead hematoma with a laceration, and the resident required assistance from staff and was transferred to the emergency room for evaluation. Subsequent medical evaluation revealed the resident sustained non-displaced fractures of multiple ribs and a confirmed apical pneumothorax. The resident was hospitalized, later readmitted to the facility on hospice services, and subsequently passed away. The incident was identified as a failure to ensure the area was free from accident hazards and that adequate supervision and safety measures, specifically the use of a safety belt on the mechanical bath chair lift, were provided to prevent accidents.
Improper Use of Audible Chair Alarm Without Assessment
Penalty
Summary
The deficiency involves the improper use of an audible chair alarm for a resident, identified as resident 17, without proper assessment, documentation, or reassessment. The resident was observed with a chair alarm clipped to her shirt, which emitted a loud noise when she attempted to move. The resident expressed discomfort with the alarm, stating it was loud and frightening. Despite the resident's ability to use a call light, the alarm was used as a measure to prevent her from getting up unassisted due to her fall risk. Interviews with staff, including a CNA and the DON, revealed that there was no formal assessment process in place before implementing the chair alarm. The CNA indicated that the alarm did not physically restrain the resident, as it could easily detach. However, the DON confirmed that the alarm was used for residents who were not safe to ambulate independently, and there was no consideration of whether the alarm could be perceived as a restraint or cause fear. Additionally, there was no documentation of a physician's order or duration of use for the alarm. The facility's policies on falls and restraints were not followed, as there was no comprehensive assessment or documentation to justify the use of the chair alarm. The resident's care plan included a silent bed alarm but lacked specific interventions for the audible chair alarm. The facility's restraint policy emphasized the need for clinical justification and documentation, which was not adhered to in this case. The lack of proper assessment and documentation led to the inappropriate use of the chair alarm, potentially impacting the resident's well-being.
Resident Lacked Accessible Call Light Due to Hand Contractures
Penalty
Summary
The provider failed to ensure that a resident with hand contractures had access to a call light she could use. Observations revealed that the resident, who communicated verbally with yes or no, did not have her call light within reach. Interviews with staff indicated that they were aware the resident could not use the standard call light due to her hand contractures. Although staff mentioned checking on her frequently, the resident was unable to activate the call light when it was placed in her hand. Further investigation revealed that the resident previously had a soft squeeze call light in another room, which she could use, but had not had access to it for at least a month. After the issue was identified, the resident was provided with a soft squeeze call light, which she was able to activate. However, another observation showed that the call light was not within her reach when she was in a specialized wheelchair, as it was clipped to her bed. The director of nursing acknowledged awareness of the issue and expressed concern over the resident not having a usable call light for an extended period.
Improper Transfer Techniques and Lack of Training for CNAs
Penalty
Summary
The provider failed to ensure that two certified nursing assistants (CNAs), H and K, applied a mechanical stand aide sling to a resident prior to use and transferred the resident safely from the bathroom to a specialized wheelchair. During an observation, CNAs H and K were seen assisting a resident from a recliner to a Broda wheelchair without initially securing the mechanical stand aide sling around the resident. The resident was visibly shaking and struggling to hold on as the CNAs attempted to position the sling while the resident was standing. Once the sling was correctly placed, they transferred the resident to the bathroom and later to the Broda chair. Further observations revealed that CNAs H and K used an unsafe method to transfer the resident into the Broda chair by tilting the chair forward, lifting the back two wheels off the ground. This method was confirmed by CNA K, who stated it was used to position the resident correctly due to his stiffness and difficulty bending. Interviews with other staff, including a registered nurse and the director of nursing, indicated that this method was not documented or approved, and there was no evidence of training for the CNAs on the proper use of the mechanical stand aide or the Broda chair. The resident involved required extensive to total assistance with activities of daily living due to late-stage dementia. The care plan specified the use of a Broda chair but did not include instructions for tilting the chair during transfers. The facility's transfer policy emphasized the importance of securing transfer surfaces and using safety straps, which were not adhered to in this case. Manufacturer instructions for both the Broda chair and mechanical stand aide also highlighted the necessity of securing the resident and locking transfer surfaces, which were not followed during the observed transfers.
Infection Control Deficiencies in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The provider failed to ensure adherence to infection control policies regarding hand hygiene and mechanical lift disinfection, as observed with two CNAs, H and K, during their interaction with a resident. During a transfer, the CNAs discovered the hand sanitizer dispenser in the resident's room was empty. CNA H left the room to find a new bottle but returned without one, and both CNAs proceeded to put on gloves without performing hand hygiene. They assisted the resident to stand using a mechanical stand aide and later discovered the resident was incontinent. CNA H exited the bathroom without gloves, retrieved a new pair, and re-entered without performing hand hygiene. After assisting the resident, CNA K performed hand hygiene in the hallway after disposing of trash, but both CNAs left the resident on the toilet without sanitizing the mechanical stand aide. They later returned to transfer the resident to a Broda chair, performing hand hygiene before donning gloves. However, they failed to sanitize the mechanical stand aide before moving on to another task, despite having sanitizer wipes available on the aide. Interviews with RN N and the infection preventionist G confirmed that the staff did not meet the expected standards for hand hygiene and equipment disinfection. The facility's policies required hand hygiene before and after glove use and the disinfection of non-critical resident care equipment, such as mechanical lifts, after each use. The CNAs' actions did not align with these policies, leading to the identified deficiencies.
Resident Elopement Due to Staff Oversight
Penalty
Summary
A deficiency occurred when a resident, who had been admitted to the nursing home from an adjoining assisted living facility, eloped from the facility without staff knowledge. The incident took place when the director of plant operations found the resident near the entrance of the adjoining hospital. Although the door alarms were functioning, the staff on duty did not recognize the incident as an elopement because the resident did not leave the campus. This oversight led to a failure in reporting the elopement within the required timeframe. The resident involved in the incident was not injured, and the deficiency was identified as a failure to ensure the safety of the resident. The staff's lack of awareness regarding the classification of the incident as an elopement contributed to the deficiency. The report highlights that the resident was not wearing a wander bracelet at the time of the incident, which was only put in place afterward. This lapse in supervision and safety measures could have resulted in harm to the resident had they not been found promptly.
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.
