Bethesda Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Webster, South Dakota.
- Location
- 129 W Hwy 12, Webster, South Dakota 57274
- CMS Provider Number
- 435071
- Inspections on file
- 19
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Bethesda Home during CMS and state inspections, most recent first.
Failure to document informed consent for psychotropic meds: Staff notified residents’ representatives of psychotropic med changes, but records did not show that the indication, risks vs benefits, or alternative treatments were explained before Seroquel, Olanzapine, trazodone, quetiapine, or Celexa were started or changed. The RN manager/IP C said consent was obtained verbally and notes recorded notifications, but the EMRs lacked specific documentation of informed consent or written consent for the med changes.
The facility failed to accurately code MDS assessments for two residents. One resident with Alzheimer’s disease, major depression, anxiety, and a psychotic disorder had MDSs that did not indicate a Level II PASRR despite prior PASRR approval for an unlimited LTC stay, and the MDS coordinator acknowledged the error. Another resident admitted with PTSD had an admission MDS that did not mark PTSD as an active diagnosis, and the MDS coordinator acknowledged the diagnosis was present on admission and that psychiatric services had been provided.
A resident with COPD and a history of thrush received budesonide nebulizer treatments, but staff did not consistently rinse the nebulizer mask or instruct him to rinse his mouth after treatments. The resident reported that nurses or CMAs often left the room during treatments and that he was not told to rinse afterward, while the EMR showed budesonide orders that specifically instructed mouth rinsing to help prevent oral thrush. Staff interviews and the manufacturer's instructions showed the nebulizer chamber and face mask were to be cleaned after each use, but practice at the facility did not consistently follow those directions.
A fentanyl patch for a resident was removed from a double-locked controlled substance drawer and then went missing before it was securely administered or accounted for. Surveyors also found another resident’s bedside medications and personal care products left unsecured in the room, opened latanoprost eye drops without dates for two residents, expired insulin syringes in medication carts and a med room, and pre-prepared meds left in a locked cart rather than being immediately administered.
The facility failed to ensure residents' privacy by not obtaining consent for audio and video monitoring devices in their rooms. Six residents had devices capable of monitoring without proper signage or staff awareness. The facility's policies were inconsistent with practices, and informed consent was not obtained, violating residents' rights.
The facility failed to implement an effective grievance process, as evidenced by unresolved grievances from two residents. One resident expressed concerns about the dining room environment and dietary preferences, which were not consistently addressed. The resident council president reported a lack of follow-up on complaints, and staff interviews revealed gaps in the grievance process. The facility's grievance policy was not effectively implemented, leading to unresolved issues and resident dissatisfaction.
The facility failed to ensure prompt responses to call lights, impacting residents' well-being. Residents reported waiting up to 45 minutes for assistance, particularly in the mornings. Call light logs confirmed these delays, with multiple instances of waits over 30 minutes. The facility was experiencing a COVID-19 outbreak, which may have contributed to the issue. Despite staff consensus on prompt response times, residents experienced incontinence accidents due to delays. The facility's call light policy was not effectively monitored, leading to documented deficiencies.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed of the risks versus benefits of psychotropic medications and alternative treatments before those medications were administered. Review of records, interviews, and policy showed that staff notified representatives of medication changes for residents with impaired cognition, but the documentation did not show that the indication for the medication, the risks and benefits, or alternative treatments were explained before psychotropic medications were started or changed. For one resident with Alzheimer’s disease, major depression, anxiety, and a psychotic disorder with delusions, the psychiatric provider changed Seroquel orders for psychosis and physically aggressive behaviors and added a PRN dose. The nurse’s note showed the representative was notified of the new orders, but there was no documentation that the resident or representative was informed of the reason for the medication change, the risks versus benefits, or alternative treatments. For another resident with neurocognitive disorder with Lewy bodies, hallucinations, dementia, and PTSD, an order for Olanzapine was entered, but there was no documentation that staff provided information to the resident or representative regarding the psychotropic medication. For a third resident with severe cognitive impairment, dementia with agitation, and insomnia, multiple psychotropic medication changes occurred, including trazodone, quetiapine, and Celexa. The record showed phone notifications to the representative and some discussion of psychiatry services and medication changes, but it did not show informed consent, written consent, or documentation that risks versus benefits were explained for the new medications or dosage changes. The RN manager/IP C stated that the facility obtained verbal consent and documented notifications, but the notes did not include specific details about risk-versus-benefit information, and the administrator acknowledged the facility did not use a written informed consent form for psychotropic medications.
MDS Coding Errors for PASRR and Active Diagnosis
Penalty
Summary
The facility failed to ensure accurate MDS coding for PASRR for one resident and for active diagnoses for another resident. One resident, admitted with diagnoses including Alzheimer's disease, major depression, anxiety, and a psychotic disorder with delusions, had a comprehensive admission MDS and a later comprehensive MDS that did not mark A1500 as yes for a Level II PASRR, even though prior PASRR documentation showed a Level II determination approving an unlimited long-term care stay. During interview, the MDS coordinator acknowledged that the resident did have a mental health diagnosis of major depressive disorder and that she had made a mistake by indicating he did not have a Level II PASRR. A second resident, admitted with PTSD, had an admission MDS that did not mark I6100 Post Traumatic Stress Disorder under psychiatric/mood disorder in section I. During interview, the MDS coordinator acknowledged the resident had PTSD on admission and had received psychiatric services before admission and again after admission with a new provider. She stated she relied on the information sent with the resident, including diagnoses, medication orders, and physician progress notes, but did not consider PTSD an active diagnosis because the resident did not have medications prescribed for it.
Failure to Follow Budesonide Nebulizer Instructions
Penalty
Summary
The nursing facility failed to ensure that budesonide nebulizer treatments were administered according to the manufacturer's instructions for one resident who had COPD and a history of thrush. Observation of the resident's room showed a nebulizer machine and mask on the bedside table, with the mask assembled and sitting on the machine. During interview, the resident stated that nurses or CMAs gave him nebulizer treatments twice daily, often left the room while he was receiving them, and sometimes returned to rinse the nebulizer mask but sometimes did not. He also stated that staff did not tell him to rinse his mouth after treatments, and he did not know he was supposed to do so. The medication chamber appeared hazy with an unknown substance, and the resident said he sometimes took a lozenge to treat thrush because one of his nebulizer medications caused it. The resident's EMR showed a physician's order for budesonide nebulizer twice daily with instructions to make sure the mouth was rinsed with water after treatment to help prevent oral thrush, and a prior order for clotrimazole troches for thrush. The record also documented that the resident had requested additional clotrimazole because he felt he had oral thrush and reported having had it before. Staff interviews showed differing practices: one RN stated she remained in the room during nebulizer treatments, shook out excess liquid, and placed the mask in a vented storage bag to dry, while the DON stated she expected the mask to be rinsed and was not aware the budesonide manufacturer's instructions required washing the nebulizer chamber and face mask with mild detergent after each administration. The provider's nebulizer policy addressed discarding excess solution and using a vented storage bag, but the manufacturer's instructions required rinsing the mouth after each nebulization and cleaning the nebulizer chamber and mask after every administration.
Medication storage, labeling, and disposal failures
Penalty
Summary
Drugs and biologicals were not consistently labeled, securely stored, or discarded in accordance with facility policy and accepted medication storage practices. A fentanyl patch for resident 35 was removed from the double-locked controlled substance drawer by RN K, but it was not immediately administered or securely maintained. RN K placed the patch on top of a Tegaderm package, carried multiple items into the resident’s room, and later discovered the patch was missing. She searched the resident’s room, the hallway, the medication cart, her shoes, and garbage bags, and additional staff searched laundry, housekeeping areas, and the vacuum, but the patch was not found. The controlled drug record later documented one patch as missing and another as wasted, and the report states the missing patch could not be witnessed as wasted because it was not located. Resident 24 had several medications and personal care products in his room, including Vicks Vaporub, Gold Bond medicated powder, Blu-Emu cream, Voltaren 1% cream, and seawater nasal spray. Observation and interview showed these items were left on tables in the resident’s room rather than being securely stored. Resident 24 stated he used the products as needed and that they were left in his room for him to use. His record showed orders allowing bedside use for some medications and a self-administration assessment indicating he could safely administer pills, creams, and ointments with setup, but the assessment also stated the self-administered medications were stored in the nursing medication cart. The facility also failed to label and discard medications with shortened expiration dates and failed to remove expired supplies from active use. Latanoprost eye drops for residents 13 and 18 were observed without a date showing when they were opened, and staff stated they did not routinely date eye drops when opened. Expired 100-unit insulin syringes were found in the medication room and in all three observed medication carts. In addition, RN G described preparing resident 6’s medication ahead of administration and placing it in a labeled medication cup in the locked medication cart until the resident returned, and RN manager/IP C observed stacked medication cups with a medication between them in medication cart C. The facility policy required medications with shortened expiration dates to be labeled upon opening, medications to be stored in locked compartments when not in use, and controlled substances to be kept in separately locked compartments.
Failure to Ensure Privacy with Audio/Video Monitoring Devices
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records by not obtaining consent for the use of audio and video monitoring devices in residents' rooms. Six residents were identified as having such devices, which included [NAME] Echo devices and iPads, capable of video and audio monitoring. Observations revealed that these devices were active in residents' rooms without any signage indicating their presence, and staff members were largely unaware of the devices' capabilities to monitor audio and video. Interviews with staff, including a CNA, RN, and LPN, indicated a lack of awareness regarding the monitoring capabilities of the devices. The LPN acknowledged that some devices could allow external parties to listen in on residents' rooms. The Director of Nursing (DON) admitted that the devices were introduced recently and were primarily used for psychosocial reasons, such as playing music, but was unaware of their full monitoring capabilities. The facility had not obtained informed consent from residents for the use of these devices. The facility's policies were inconsistent with the practice observed. The provider's policy from December 2024 stated that video and audio monitoring were not allowed in resident rooms, yet devices capable of such monitoring were present. A new policy regarding [NAME] devices was developed only after the survey, indicating a lack of prior protocol. The South Dakota State Long-Term Care Ombudsman Program's resident rights handbook requires consent and signage for video monitoring, which the facility failed to implement.
Ineffective Grievance Process in LTC Facility
Penalty
Summary
The facility failed to implement an effective grievance process for residents, as evidenced by the lack of documentation, investigation, and follow-up on grievances reported by two residents. Resident 32, who had been living in the facility for nearly three years, expressed concerns about the dining room being cold, the cleanliness of the air exhaust vent, and the accuracy of the menu board. Additionally, she had specific dietary preferences due to her diabetes and personal dislikes, which were not consistently honored. Despite discussing these issues with staff, no actions were taken to address her grievances, and there was no documentation of these concerns in the grievance records. Resident 10, the president of the resident council, also reported issues with the grievance process. She was unaware of how complaints from the resident council were addressed and had not seen any concern forms. The resident council meetings, coordinated by Activity Director F, lacked proper documentation and follow-up on concerns raised by residents. The minutes did not reflect resolutions to previous issues, and there was no written communication regarding the concerns discussed during the meetings. Interviews with staff, including the Licensed Social Worker (LSW) H and Director of Nursing (DON) B, revealed gaps in the grievance process. LSW H, who was responsible for handling grievances, admitted to not being aware of the difference between a complaint and a grievance according to the facility's policy. Furthermore, there was no Grievance Committee in place, and grievances were not reviewed during Quality Assurance meetings. The facility's grievance policy outlined the need for a formal process, but this was not effectively implemented, leading to unresolved grievances and dissatisfaction among residents.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to maintain the physical, mental, and psychosocial well-being of residents by not ensuring prompt responses to call lights. Interviews with residents revealed that they experienced significant delays in receiving assistance after activating their call lights. For instance, one resident reported waiting up to 45 minutes for help, particularly in the mornings when she needed assistance with dressing. Another resident expressed similar concerns about long wait times, which he planned to address in an upcoming care conference. The review of call light logs confirmed these delays, showing multiple instances where residents waited over 30 minutes for assistance. The facility was experiencing a COVID-19 outbreak, which the MDS coordinator suggested might have contributed to the extended wait times. However, the Director of Nursing (DON) was unaware of any reports of long wait times and acknowledged that the recorded wait times were unacceptable. The facility's call light policy emphasized the importance of promptly answering call lights, yet there were no audits conducted to monitor compliance with this policy. Interviews with staff, including LPNs and RNs, indicated a consensus that call lights should be answered within five to fifteen minutes. Despite this, residents reported incidents where they were left waiting for extended periods, leading to incontinence accidents. The facility's grievance records also highlighted past issues with delayed responses to call lights, including a resident being left on a commode for two hours. The facility's staffing model aimed to promote resident quality of life, but the current practices did not align with this goal, as evidenced by the documented deficiencies in call light response times.
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.
