Bethesda Of Beresford
Inspection history, citations, penalties and survey trends for this long-term care facility in Beresford, South Dakota.
- Location
- 606 W Cedar, Beresford, South Dakota 57004
- CMS Provider Number
- 435080
- Inspections on file
- 22
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Bethesda Of Beresford during CMS and state inspections, most recent first.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Surveyors found that staff did not consistently document completion of kitchen cleaning tasks or coffee temperature checks, and a dietary aide failed to perform required hand hygiene before and after handling food and serving meals. These actions were not in accordance with the facility's policies for sanitation and infection prevention.
A resident with an open surgical wound on the ear was not placed on enhanced barrier precautions as required by facility policy. Observations showed no signage or PPE available, and staff confirmed that EBP had not been implemented since the surgical procedure, despite the resident's ongoing wound care needs.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
The facility failed to provide Bed Hold Notices to four residents prior to their transfer to the emergency department for various medical conditions. Although emergency contacts were notified, there was no documentation of bed hold notifications. The administrator misunderstood who was responsible for issuing these notices, leading to the deficiency.
The provider failed to ensure sufficient nursing staff to answer call lights in a reasonable time for five residents. One resident reported waiting 20 to 30 minutes, another noticed longer wait times at night, and a third sometimes waited for hours at night. A resident experienced long wait times that led to incontinence episodes, and another's call light was non-functional for two days. The night shift staffing consisted of only one CNA and one nurse, contributing to the longer wait times.
The provider failed to follow necessary food safety guidelines for storage, labeling, and sanitation in the kitchen. Observations revealed undated and dented cans, expired chlorine testing strips, improper chemical storage, and significant dust and grime on kitchen equipment. Interviews indicated a lack of awareness and adherence to protocols, with no consistent cleaning schedules or logs for the kitchen and ice dispensers.
The provider failed to ensure accurate PBJ data submission to CMS for three federal fiscal quarters, resulting in deficiencies such as excessively low weekend staffing and failure to have licensed nursing coverage 24 hours per day. The inaccuracies were identified through a review of PBJ data, staff schedules, and timecards, and confirmed by the administrator.
The provider failed to address Legionella monitoring and prevention in the infection control program, potentially affecting all 35 residents. The administrator and maintenance director confirmed no water testing for Legionella had been performed, and the city's municipal water department did not monitor for it. The facility had no Legionella monitoring or prevention plan.
The provider failed to maintain a clean and homelike environment in several areas, including the activities room, resident rooms, mechanical lifts, hand sanitizer dispensers, and the scale room. Observations revealed clutter, dust, dirt, and damaged surfaces, while interviews with staff highlighted systemic issues in cleaning and maintenance routines. The Maintenance Requisition log showed incomplete requests, indicating poor communication and follow-up.
The provider failed to make grievance information and forms readily available to residents and their representatives. Residents were unaware of the grievance official and how to file a grievance. Observations showed that grievance information was not in prominent locations, and the forms were kept out of residents' reach. The admission packet and grievance policy also lacked specific details about the grievance official and the process.
The provider failed to ensure expired medications were not administered to residents and did not remove and discard expired medications from two medication carts. Observations revealed several bulk medications past their expiration dates, and interviews with staff confirmed that expired medications were missed and left on the cart. The facility's policy required proper labeling, storage, and disposal of expired medications, but these guidelines were not followed.
The provider failed to ensure the regular safety inspection of bed rails for two residents. One resident, who had a stroke and limited mobility, had bed rails in the up position but was not observed using them. Another resident had a bed rail near the wall but did not use it. The maintenance director did not assess or monitor the bed rails, contrary to the facility's policy requiring regular maintenance and individual evaluations.
The provider failed to ensure the resident call light system was functioning for two residents. One resident reported waiting hours for assistance, and observations confirmed the call light did not activate properly. Another resident's call light malfunctioned, and staff provided a different one. The facility lacked regular preventative maintenance and had an unreliable call light system computer program.
The provider failed to ensure that the contact information for the ombudsman and the SD DOH was posted in accessible locations for all residents, visitors, and families. Residents were unaware of how to contact the ombudsman or file a complaint with the SD DOH, and the admission handbook contained incorrect and outdated contact information.
The provider failed to make the most recent survey results accessible to all residents and their representatives. Residents were unaware of their right to read the state survey results or where to find them. Observations confirmed that the survey results were not made available, and the administrator confirmed that the survey binder had been removed from the front lobby in January 2024 after a water leak. The facility resident rights document indicated that survey results should be located at the nurses' station and next to the business office.
The provider failed to update a resident's code status from full code to DNR in their medical records, despite a care conference note and an Expression of Healthcare Preferences form indicating the change. The administrator admitted that the necessary steps to update the physician's orders and the EMR dashboard were not completed.
The provider failed to develop, revise, and implement comprehensive care plans for two residents, leading to deficiencies in nail care and range of motion exercises. One resident did not receive necessary hand splint use and exercises, while another had inadequate nail care and range of motion interventions. The care plans were not updated to reflect changes in the residents' conditions, resulting in inadequate care.
The provider failed to ensure ongoing restorative nursing programs for two residents with hemiplegia and hemiparesis, resulting in a lack of range of motion exercises and use of prescribed splints. Both residents expressed dissatisfaction with the absence of these programs, and the Director of Nursing confirmed that they had not been assessed or provided with necessary restorative care.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report excerpt.
Failure to Consistently Follow Food Safety and Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's food safety and sanitation practices. Observations revealed that weekly kitchen cleaning tasks were not consistently documented as completed, with 13 out of 40 tasks unmarked for one week and 14 out of 40 for another. Additionally, temperature monitoring and documentation for the coffee machine were incomplete, with only 6 out of 33 required temperature checks recorded. Staff interviews indicated confusion regarding whether temperature checks were still required after the coffee machine was calibrated, despite the dietary manager and administrator expecting ongoing monitoring and documentation. Hand hygiene practices were also found to be deficient. A dietary aide was observed failing to perform hand hygiene before and after checking food temperatures, serving meals, and handling resident food items. The aide acknowledged that hand hygiene should have been performed at these times. The facility's policies required staff to maintain sanitation through a comprehensive cleaning schedule and to practice accepted hand hygiene to prevent infection, but these standards were not consistently followed as evidenced by the observations and staff interviews.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Surgical Wound
Penalty
Summary
A deficiency was identified when a resident with an open surgical wound on the right ear, resulting from the removal of squamous cell carcinoma, was not placed on enhanced barrier precautions (EBP) as required by facility policy. Observations revealed the resident had a bandaged ear with visible blood, and the electronic medical record documented a slow-healing surgical wound with drainage and red, lump-like tissue. Despite these findings, there was no documentation of EBP implementation in the resident's record. Further observations showed there were no signs indicating EBP inside or outside the resident's room, nor was personal protective equipment (PPE) such as gowns and gloves available for staff use during contact care. During wound care, a registered nurse used gloves but did not utilize a gown, and confirmed that EBP had not been initiated since the surgical procedure. The interim director of nursing/infection preventionist acknowledged that EBP should have been in place for the resident due to the open wound, in accordance with the facility's policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The provider failed to ensure that a Bed Hold Notice form was given to four sampled residents prior to their transfer to the emergency department. Each of these residents required hospitalization for various medical conditions, including nausea/vomiting, gastrointestinal bleeding, sepsis, and pneumonia. Despite notifying the residents' emergency contacts or power of attorneys about the need for emergency room evaluations, there was no documentation found regarding the notification of the residents' bed hold status. An interview with the administrator revealed that there was a misunderstanding about who was responsible for issuing the bed hold notices. The administrator believed that the business manager was handling the notices, but this was not the case. The facility's policy stated that a bed would be held for the resident during their absence if the resident or responsible party agreed to pay the established base room rate, and that consent should be obtained within 48 hours of transfer. However, this policy was not followed, resulting in the deficiency.
Insufficient Nursing Staff Leads to Long Call Light Wait Times
Penalty
Summary
The provider failed to ensure there were sufficient nursing staff to answer call lights in a reasonable time for five of thirty-five sampled residents. Resident 4 reported waiting 20 to 30 minutes for someone to answer his call light, with the longest wait time being 40 minutes. Resident 3 noticed longer wait times at night, with 19 instances of wait times over 15 minutes and the longest being 30 minutes. Resident 5 sometimes waited for hours at night, and her call light was found to be non-functional due to a dead battery, with one instance of a 40-minute wait time. Resident 21, who was there for therapy after a hip fracture, experienced long wait times that led to incontinence episodes, with the longest wait time being 109 minutes. Resident 13's daughter also noticed longer wait times, usually around 30 minutes, and the resident's call light was non-functional for two days. The night shift staffing consisted of only one CNA and one nurse from 10:00 p.m. to 6:00 a.m., which contributed to the longer wait times. The facility's call light policy did not define an acceptable time frame for answering call lights. Interviews with staff revealed that some charted continence status immediately, while others did so later, potentially leading to discrepancies in records. The administrator acknowledged awareness of the long call light wait times and noted that the night shift staff consisted of one CNA and one nurse, with a 30-minute overlap between shifts to provide time for shift-to-shift reports. The resident council also reported difficulties in getting staff to answer call lights in the evening, with one resident waiting in the bathroom for 45 minutes and another calling the facility on her cell phone after waiting more than 20 minutes. The facility's revised call light policy aimed to ensure residents always had a method of calling for assistance and that staff responded promptly, but it did not specify an acceptable response time. The staffing schedules confirmed the limited night shift staffing, which likely contributed to the long wait times experienced by the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The provider failed to ensure necessary food safety guidelines were implemented and followed for appropriate storage and labeling of food and chemical items, appropriate monitoring of the low-temperature dishwasher, and cleaning and sanitary maintenance of the kitchen. Observations revealed multiple issues including undated and dented cans in the dry storage room, expired chlorine testing strips, and improper storage of chemicals near food preparation areas. Additionally, there was significant dust and grime on ceiling vents, kitchen equipment, and utensils, as well as food build-up in various kitchen appliances and areas. Interviews with staff members, including the dietary manager and maintenance director, indicated a lack of awareness and adherence to proper food safety and sanitation protocols. The dietary manager admitted to not dating cans upon receipt and being unaware of the expired chlorine testing strips. There were no consistent cleaning schedules or logs for the kitchen and ice dispensers, and the dietary manager was observed handling food without wearing a beard net, contrary to the facility's policy. The facility's policies on sanitation, food storage, and dishwasher maintenance were not followed, leading to the observed deficiencies. The ice dispensers had not been cleaned in the last six months, and there were no logs to document their cleaning. The provider's policies required proper labeling and dating of leftovers, regular checking of expiration dates, and the use of a comprehensive cleaning schedule, none of which were adequately implemented, resulting in the identified deficiencies.
Inaccurate PBJ Data Submission
Penalty
Summary
The provider failed to ensure that Payroll Based Journal (PBJ) data was accurately completed before submission to the Center for Medicare and Medicaid Services (CMS) for three of four federal fiscal quarters. Specifically, the PBJ data for Quarter 2, 2023; Quarter 3, 2023; and Quarter 1, 2024, contained inaccuracies. The inaccuracies included excessively low weekend staffing for Quarter 3, 2023, and failure to have licensed nursing coverage 24 hours per day on multiple dates across all three quarters. These deficiencies were identified through a review of the PBJ data submitted to CMS, staff schedules, and timecards, as well as interviews with facility staff. The administrator confirmed that the staffing schedules were correct and that the facility had met the requirement to have licensed nursing coverage 24 hours per day on the dates in question. However, the administrator was unaware that the staffing data had been inaccurately submitted to CMS. The former business office manager, who was responsible for submitting the staffing data, had stopped working for the facility in October 2023. The administrator speculated that the former employee had been submitting the staffing data incorrectly but was unsure why the most recent quarter's staffing data was also incorrect.
Lack of Legionella Monitoring and Prevention
Penalty
Summary
The provider failed to ensure that Legionella monitoring and prevention were addressed in the infection control program, potentially affecting all 35 residents within the facility. The infection prevention and control program, reviewed on 10/27/21, lacked any mention of Legionella prevention and monitoring. During an interview on 4/25/24, the administrator was unaware of any water testing for Legionella, and the Director of Nursing, who was the infection preventionist, was not available for an interview. The Maintenance Director revealed that no testing for Legionella had been performed on the facility's water supply, which was connected to the city's municipal water system. The city's municipal water department confirmed they did not monitor for Legionella, only the pH of the water supply. The Maintenance Director confirmed that the water had not been tested for Legionella in the three years he had been working at the facility. The administrator confirmed that there was no Legionella monitoring or prevention plan as part of the facility's infection control program.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The provider failed to maintain a clean and homelike environment in several areas of the facility, including the activities room, resident rooms, mechanical lifts, hand sanitizer dispensers, and the scale room. Observations revealed clutter, dust, dirt, and damaged surfaces in these areas. For instance, the activities room had glitter, confetti, and various art supplies scattered around, while the scale room had stained carpets and an unclean scale. Multiple resident rooms had issues such as sharp edges, clutter, and dirty surfaces, which were confirmed through both observation and resident interviews. Additionally, mechanical lifts were found to be filthy and missing safety components, and hand sanitizer dispensers were soiled with congealed sanitizer and dust. Interviews with staff members, including a CNA, environmental services technician, and maintenance director, highlighted systemic issues in the facility's cleaning and maintenance routines. The environmental services technician admitted to being the only housekeeper for the week and acknowledged that there was no regular deep cleaning schedule for long-term residents. The maintenance director revealed that he kept a mental note of repairs needed and performed room checks only once a month. He also mentioned that larger repairs were usually done when residents moved out. The CNA confirmed that nursing staff were responsible for cleaning mechanical lifts but admitted there were cleanliness concerns. Review of the provider's Maintenance Requisition log showed that several maintenance requests had not been completed, including a request to fix a hole in a wall and exposed bed control cord wires. The log also contained a note indicating that housekeeping was not following up on requests. These findings indicate a lack of effective communication and follow-up between housekeeping, maintenance, and nursing staff, contributing to the overall deficiency in maintaining a clean and homelike environment for residents.
Failure to Provide Accessible Grievance Information
Penalty
Summary
The provider failed to make information on how to file a grievance and the location of grievance forms readily available to residents and their representatives. During an interview with the resident council, it was revealed that residents were unaware of who the grievance official was and how to file a grievance. Observations of the facility's lobby and public areas showed that the grievance official's contact information, instructions on how to file a grievance, and the grievance forms were not in prominent locations. The administrator confirmed that she was the grievance official and expected residents to write grievances on regular paper, which she would then transfer to the official form. However, the information on the grievance process was not easily accessible, and the forms were kept in a location where residents could not reach them due to concerns about a resident who had a habit of taking items from the nurses' station. The review of the provider's admission packet and grievance policy revealed further deficiencies. The admission packet mentioned that forms were available by the front office but did not specify who the grievance official was or include a grievance form. The grievance policy stated that information on the internal grievance process would be provided upon request but did not specify who the grievance official was. Despite a plan of correction being implemented after a previous survey, the facility was still found to be non-compliant in making grievance information and forms readily accessible to residents and their representatives.
Expired Medications Not Removed from Medication Carts
Penalty
Summary
The provider failed to ensure expired medications were not administered to residents and did not remove and discard expired medications from two medication carts. Observations revealed several bulk medications past their expiration dates, including Senna, TUMS, multivitamins, calcium tablets, aspirin, Milk of Magnesia, and Tylenol. Interviews with LPN F and RN K confirmed that the dates written on the bottles were the dates they were opened, and some expired medications were missed and left on the cart. Both nurses acknowledged that expired medications should have been removed and disposed of properly. The facility's policy stated that medications should be labeled and stored according to professional principles, and expired medications should be disposed of according to procedures. The policy also required nurses to check expiration dates before administering medications. Despite these guidelines, expired medications were found on the medication carts, indicating a failure in adherence to the policy. The administrator acknowledged the issue and mentioned that the director of nursing was unavailable due to personal reasons, and the pharmacist had recently audited the medications.
Failure to Ensure Regular Safety Inspection of Bed Rails
Penalty
Summary
The provider failed to ensure the regular safety inspection of bed rails for two residents. Resident 7, who had a stroke five years ago and could not use her right leg or arm, had bed rails on her bed in the up position. She mentioned using the bed rails sometimes for repositioning. However, a CNA stated that she never observed Resident 7 using the bed rails. Resident 2, who was sitting in her wheelchair while a CNA made her bed, had a bed rail near the wall, but the CNA stated that the resident did not use the bed rail. Resident 2 did not respond when questioned about the use of the rail. The maintenance director revealed that he did not assess the bed rails, did not have measurements or any log with bed rail information, and did not perform annual checks or monitoring of the bed rails once they were placed on the residents' beds. The facility's Bed Inspection and Bed Rail Policy stated that regular maintenance and individual bed rail evaluations were required to ensure safety, but these procedures were not followed. The policy also mentioned that the facility would provide education to residents or their representatives about the risks and benefits of bed rail use, which was not evident in the findings.
Resident Call Light System Malfunction
Penalty
Summary
The provider failed to ensure the resident call light system was functioning for two of the sampled residents. Resident 5 reported waiting hours at night for assistance when using her call light. During an observation, it was noted that the call light did not activate the red indicator light, and there was no indication outside the room that the call light was on. A CNA confirmed that the call light was not working and took it to maintenance for repair. The LPN also confirmed the malfunction and mentioned that someone would have to report the issue for it to be addressed. The call light audit report showed no record of the call light activation at the time it was pressed, and it only started working again after a delay. There was no regular preventative maintenance for the call lights, and staff reported issues verbally or in a maintenance request book, which was not always followed up on promptly. Resident 13's daughter reported a similar issue where the call light was not working, and staff had to provide a different call light. The administrator acknowledged the problem and mentioned that the call light system's computer program was unreliable, causing further complications in reassigning call lights to the correct room numbers. The maintenance director confirmed the lack of a preventative maintenance program and stated that issues were addressed only when reported. The call light audit for Resident 13 showed a low battery signal and subsequent malfunction, with a new call light provided days later. The provider's maintenance requisition records showed unresolved call light issues, and the call light policy lacked procedures for handling malfunctions and regular maintenance checks.
Failure to Post Ombudsman and SD DOH Contact Information
Penalty
Summary
The provider failed to ensure that the contact information for the ombudsman and the South Dakota Department of Health (SD DOH) was posted in a location accessible to all 35 current residents, visitors, and families. During an interview with the resident council, it was revealed that the residents were unaware of where to find the ombudsman's contact information and did not know they could contact the SD DOH directly or file a complaint. Observations confirmed that the ombudsman's contact information was posted in the entryway vestibule, which required a door code to access, and in the social worker's office, which was not always accessible to residents. Additionally, there was no SD DOH contact information or a statement that residents could file a complaint with the SD DOH posted anywhere in the facility. The administrator confirmed that the ombudsman's contact information was only posted in the social worker's office and that the SD DOH contact information was not posted. The admission handbook was also found to be deficient, as it contained incorrect and outdated contact information for the state ombudsman program and the SD DOH complaint coordinator. The table of contents listed State and Federal Contacts on page 19, but there was no page 19, and the contact information started on page 18, followed by a mislabeled page 2. This lack of accessible and accurate information prevented residents from knowing how to file complaints or seek assistance from the ombudsman or SD DOH.
Failure to Make Survey Results Accessible to Residents
Penalty
Summary
The provider failed to make the most recent survey results accessible to all residents and their representatives. During an interview with the resident council, it was revealed that residents were unaware of their right to read the state survey results or where to find them. Observations of the lobby and public areas confirmed that the survey results were not made available. An interview with the administrator confirmed that the survey results were not currently posted and that the survey binder had been removed from the front lobby in January 2024 after a water leak. A review of the facility resident rights document in the admission packet indicated that residents have the right to examine the results of the most recent survey, which should be located at the nurses' station and next to the business office.
Failure to Implement Revised Advanced Directive
Penalty
Summary
The provider failed to implement a revised advanced directive for one resident. The resident's paper and electronic medical records indicated a full code status, despite a care conference note and an Expression of Healthcare Preferences form indicating a change to do not resuscitate (DNR). The administrator acknowledged that the necessary steps to update the resident's code status were not completed, including updating the physician's orders and the electronic medical record (EMR) dashboard. The administrator admitted that she did not follow up with the new Expression of Healthcare Preferences form, which should have been sent to the physician for signature and uploaded to the EMR. The facility's Denoting Code Status policy did not include the steps or expectations mentioned by the administrator, such as the use of a stamp to ensure the process was followed. This oversight resulted in the resident's code status not being accurately reflected in their medical records.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The provider failed to develop, revise, and implement a comprehensive person-centered care plan for two residents, specifically addressing nail care and range of motion exercises. Resident 3 had a right-hand splint and a schedule for its use, but she reported not wearing the splint for a long time and not receiving any range of motion exercises. The care plan for Resident 3 had not been updated after her discharge from occupational therapy, and there were no goals or interventions related to her right-hand contracture or limited range of motion in her right arm. The registered nurse and the administrator were unable to provide documentation or confirm the use of the hand splint for Resident 3, and there was no policy for the restorative nursing program in place. Additionally, the care plan had not been revised to reflect changes in Resident 3's condition and needs after her therapy ended. This lack of documentation and follow-up led to a failure in providing necessary care for Resident 3's condition, including the use of the hand splint and range of motion exercises. The interdisciplinary team did not adequately assess and update the care plan to address Resident 3's needs, resulting in a deficiency in her care. Resident 5 had long, jagged, and thickened fingernails with dark residue under the tips, and she reported not receiving exercises for her hands. Despite having a physician's order for a blue palm protector for her right hand, there was no documentation of nail care or refusal of nail care in her records. The care plan for Resident 5 did not include any interventions related to her limited range of motion or nail care. Interviews with staff revealed inconsistencies in the provision of nail care and the use of the blue palm protector. The director of nursing confirmed that Resident 5 had not been assessed for a restorative program, and the care plan was not updated to reflect her current needs. This lack of proper assessment and documentation led to a deficiency in providing necessary care for Resident 5's condition, including nail care and range of motion exercises. The provider's care planning process policy emphasized the importance of a comprehensive, individualized plan of care for each resident, but this was not followed for Residents 3 and 5. The interdisciplinary team failed to assess, individualize, and evaluate the effectiveness of the care plans, resulting in deficiencies in addressing the residents' needs and conditions. The care plans were not revised on an ongoing basis to reflect changes in the residents' conditions and the care they were receiving, leading to inadequate care for both residents.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The provider failed to ensure an ongoing restorative nursing program for two residents at risk for a decline in range of motion (ROM). Resident 3 had a right-hand splint with a wearing schedule posted in her room, but she indicated she had not worn the splint for a long time and was not receiving any range of motion exercises. Her medical records showed a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, affecting her right side, and a contracture of the right hand. Despite these conditions, there was no documentation supporting her participation in a restorative program, and her care plan lacked interventions related to her right-hand contracture. The Occupational Therapy Discharge Summary indicated a splint and brace program, but there was no follow-up in the electronic medical record (EMR) to ensure compliance with this program. Similarly, Resident 5, who had hemiplegia and hemiparesis following a cerebral infarction affecting her left side, was observed with minimal movement in her hands and expressed dissatisfaction with not receiving exercises for her hands. Her medical records included a physician order for a palm protector due to contracture, but there was no evidence of a restorative program in place. Interviews with therapy staff revealed that both residents should have had restorative programs, but these were not implemented. The Director of Nursing (DON) acknowledged that not all residents had been assessed for restorative programs and that Residents 3 and 5 had not been evaluated or provided with such programs, despite their needs.
Latest citations in South Dakota
Failure to Follow EBP and Hand Hygiene Practices: Staff did not wear gowns or gloves, did not perform hand hygiene, and did not clean an EZ stand lift after providing high-contact care to a resident on EBP with a Foley catheter. Staff also provided toileting care to a resident with open stage II pressure ulcers without gowns, and a housekeeper handled resident-room surfaces and items with unclean hands while cleaning rooms. Facility policy required gown and glove use for EBP, cleaning reusable equipment between residents, and hand hygiene after resident contact and glove removal.
A resident with severe cognitive impairment, TBI, and dementia with behavioral disturbances used a one-piece jumpsuit identified as a restraint intervention to address genital exposure and related behaviors. The EMR showed consent and physician approval, but the quarterly MDS and care documentation did not show whether the garment remained needed, whether less restrictive alternatives had been tried, or whether restraint reduction or elimination had been considered. Staff interviews confirmed the resident had not worn the garment in a long time, and the DON stated there was no restraint-specific documentation form to track its use or reassess the need for it.
Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
Failure to assess, document, and report new pressure ulcers: A resident with a pelvic fracture and intact cognition developed stage II pressure ulcers on both inner buttocks and a new pressure ulcer on the heel. Staff interviews and record review showed the DON/wound nurse did not document the heel wound or notify the MD, did not notify the MD when the left buttock ulcer was identified, and wound monitoring was not completed daily as required by the facility's own process.
Staff failed to follow a resident’s care-planned transfer needs. The resident had severely impaired cognition, a moderate fall risk score, and required dependent assistance with transfers, including a Hoyer lift with 2 staff or a sit-to-stand lift. Two CNAs lifted her by the underarms and pivoted her instead of using the ordered transfer method, and one CNA stated she did not use a gait belt because the resident was too tiny. The DON acknowledged the transfers were improper and unsafe because staff did not follow the care plan or Kardex.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Staff failed to honor several residents’ stated preferences regarding where they undressed for bathing, affecting their dignity and privacy. One resident reported that a CNA repeatedly undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his expressed wish to undress in the shower room. Other residents described similar experiences, stating that the CNA did not ask their preferences and routinely undressed them in their rooms before covering them with a sheet or blanket and taking them to the tub or shower room. Staff interviews confirmed that residents, particularly those requiring a mechanical lift, were typically undressed in their rooms and then transported covered, and the DON stated that facility protocol was to follow resident preference, consistent with the written dignity and privacy policy.
A resident reported that a contracted travel CNA placed hands down his pants while he was in bed, which he described as groping and not part of his usual care routine. Two RNs received this allegation; one counseled the CNA but did not notify leadership and did not know the required reporting time frame, while the other, who knew the 2‑hour reporting requirement, also failed to promptly inform the DON or administrator, delaying notification to state authorities and omitting contact with law enforcement and the ombudsman. In a separate incident, a resident’s family member reported suspected financial abuse to the social services designee, who informed the administrator, but the concern was not reported to the state agency or investigated as an abuse allegation; instead, the family was only given contact information for outside agencies. These actions did not follow the facility’s abuse policy requiring immediate internal reporting, prompt investigation, and timely reporting of all abuse and misappropriation allegations to the state agency.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
Failure to Follow EBP, Equipment Cleaning, and Hand Hygiene Practices
Penalty
Summary
Infection prevention and control practices were not followed during care for a resident on enhanced barrier precautions (EBP) who had a Foley catheter. During a transfer from a wheelchair to a recliner using an EZ stand lift, two CNAs/RMAs did not wear gowns or gloves, did not perform hand hygiene after the transfer, and one CNA/RMA placed the lift outside the resident’s room without cleaning it. One of the CNAs/RMAs stated she was expected to wear a gown and gloves for the transfer and remove them afterward, and the other stated she should have worn a gown and gloves and cleaned the lift after use. A second resident had open stage II pressure ulcers to both buttocks and a new pressure ulcer on the right heel, but was not placed on EBP. During observed toileting assistance, an RN and a CNA wore gloves but did not wear gowns while providing care to the resident’s open buttock wounds. The CNA applied barrier cream to the pressure ulcers and the rest of the buttocks. The RN stated the resident did not need EBP because the wounds did not have drainage, and the ADON/IP stated the resident was not on EBP because the pressure ulcer was not chronic. Housekeeping staff also did not follow hand hygiene practices while cleaning resident rooms. A housekeeper removed a mop head with bare hands, touched door handles without washing hands, and used unclean hands while moving between rooms and handling resident items and bathroom surfaces. The housekeeper stated she was supposed to wash her hands after cleaning a bathroom, after mopping, and between rooms, and the director of food and nutrition/housekeeping and housekeeping supervisor confirmed staff were to wash hands before and after glove use, after bathroom cleaning, and before and after mopping. Facility policy stated EBP required gown and glove use for high-contact care such as transferring and toileting, reusable equipment was to be cleaned and disinfected between residents, and hand hygiene was the primary means to prevent the spread of healthcare-associated infections.
Lack of Documentation for Ongoing Use of One-Piece Garment Restraint
Penalty
Summary
The provider failed to document whether one resident who used a one-piece jumpsuit as a restraint intervention was a candidate for restraint reduction, a less restrictive restraint method, or restraint elimination. The resident had severe cognitive impairment, a history of traumatic brain injury, and dementia with behavioral disturbances. He was observed seated in his wheelchair at breakfast and later in his recliner, repeatedly moving his feet, rocking his trunk, and placing his hand in and out of the waistband of his sweatpants. His EMR showed that the jumpsuit had been identified as a restraint intervention and that the resident's spouse had signed informed consent for its use. The record showed the resident had ongoing behaviors involving fondling himself and exposing his genitals, and staff requested physician approval for a one-piece garment to protect his dignity and prevent exposure to others. The physician approved the request. The quarterly MDS indicated the resident used a trunk restraint on a less-than-daily basis, and the MDS nurse's note stated that when available the resident would wear the one-piece jumpsuit. However, that assessment did not include documentation supporting continued use or discontinued use of the garment, and there was no indication that other alternatives had been tried. The behavioral tracking record documented other targeted behaviors, but fondling and exposing his genitals were not identified as targeted behaviors on that assessment. During interviews, an LPN stated the jumpsuit's zipper was on the backside of the garment, restricting the resident's access to his genitals, and said he had not worn it in a long time because of physical and cognitive decline. A CNA also stated she had not seen him wear the garment. The MDS nurse found the jumpsuit hanging in the resident's closet and acknowledged she did not know whether staff had completed restraint-related documentation. The DON stated there was no restraint-specific form to document when the jumpsuit was worn, what precipitated its use, what less restrictive interventions were tried, or how long it was worn, and acknowledged that without such documentation the quarterly assessment could not fully determine whether the jumpsuit remained needed or could be discontinued. The facility's restraint policy required least restrictive use, ongoing reevaluation, and quarterly review for restraint reduction, less restrictive methods, or elimination.
Failure to Follow Ordered Urology Consultation
Penalty
Summary
The nursing facility failed to follow a physician-ordered urology consultation for a resident with urinary retention and a Foley catheter. The resident had been hospitalized for a left femur fracture, and hospital records showed the Foley catheter was removed and later reinserted after a failed trial without catheter. After discharge to the skilled nursing facility, the physician was faxed about discontinuing the Foley catheter and responded to start Alfuzosin for 4 days and then attempt a trial without the catheter. When that trial failed, the physician ordered the Foley restarted and follow-up with urology. Subsequent physician progress notes in February, March, and April documented referral to urology for further evaluation and care, and the resident’s catheter care plan addressed Foley care but did not include a plan for removing the catheter. During interviews, an LPN stated she knew the resident was expected to be seen by a urologist but it had not yet occurred and she was not sure why. The DON and ADON/IP stated the physician was expected to call the urologist to make the referral and that the urology office would then confirm the appointment time. The ADON/IP recalled discussing the urology consultation with the physician during January rounds, but confirmed she did not discuss the status of the consultation during February, March, or April rounds and had no other discussions with the physician about it. The DON acknowledged the failure to follow the January physician-ordered urology consultation was 100% on the facility.
Failure to assess, document, and report new pressure ulcers
Penalty
Summary
The provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers for one resident who had returned to the facility from the hospital with a pelvic fracture and weakness and had an intact BIMS score of 15. The resident had a stage II pressure ulcer to the right inner buttock identified on 4/6/26, and later a stage II pressure ulcer to the left inner buttock was identified on 4/27/26. The record showed wound assessments on the right inner buttock, but the report states the wound assessment documentation was not completed weekly as required, and the physician was not notified when the left inner buttock ulcer was identified. The resident was observed sitting in a wheelchair on a Roho pressure-relief cushion and stated she had an open sore on her bottom. Staff interviews confirmed she had pressure ulcers on both inner buttocks, and a CNA reported finding a new pressure ulcer on the resident's right heel that was boggy and dark red and purple in color. An LPN stated the resident had stage II pressure ulcers to both inner buttocks and that the new right heel pressure ulcer had been found the previous day. The DON/wound nurse later stated she was not aware of the right heel pressure ulcer and could not find documentation of it or documentation that the physician had been notified. The record review showed the resident's wound assessments were completed on several dates for the right inner buttock ulcer, with measurements and descriptions documented, and the care plan addressed pressure ulcers to both inner buttocks. However, the DON/wound nurse stated nurses did not monitor pressure ulcers daily and that weekly skin assessments were the routine process. The provider's policy required nurses to document and report pressure ulcers, and the change-in-condition policy required physician notification within 24 hours for a significant change of condition. The DON/wound nurse stated she did not notify the physician when the left inner buttock ulcer was identified and planned to wait until the physician rounded at the facility later.
Unsafe Transfers Not Followed for a Resident With Care-Planned Lift Needs
Penalty
Summary
The nursing home failed to ensure safe transfers for resident 11, who had severely impaired cognition, a moderate fall risk score, and care-planned transfer needs requiring dependent staff assistance. Her revised care plan stated that she usually required a Hoyer lift with staff assist x 2 for transfers when she was not placing her feet on the ground for a pivot transfer with a gait belt and staff assist x 1-2, or a sit-to-stand lift. The resident was observed in the dining room being lifted by CNA F and CNA/RMA E, who each placed an arm beneath her underarms, raised her to standing, pivoted her, and lowered her into her wheelchair. CNA F later transferred the resident from the wheelchair to a recliner in the same manner and stated the resident could not bear her full weight and that she did not use a gait belt because the resident was too tiny. A separate observation showed CNA/RMA G using a sit-to-stand lift to transfer resident 11 from her wheelchair to the toilet and referring to the Kardex to confirm that a mechanical lift was required. The DON/wound nurse stated therapy assessed residents' mobility and transfer needs, those recommendations were added to the care plan, and the care plan information was then transferred to the Kardex so staff would know how to care for the resident. The DON acknowledged that CNA/RMA E and CNA F improperly and unsafely transferred resident 11 by failing to follow the transfer recommendations in the care plan and Kardex.
Failure to Maintain Safe Bed Systems and Prevent Accidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bed environment free from entrapment hazards and to provide adequate supervision and accident prevention for multiple residents. Surveyors observed that several residents had loose side rails or grab bars and mattresses that were not secured or properly fitted, creating gaps between the rails, mattress, and bedframe. One resident’s bilateral side rails could move away from the bed one to two inches, and there was a five‑inch gap between the top of his mattress and the headboard. Another resident, who was legally blind and had previously fallen out of bed during a dream and sustained a brain bleed, had a left side rail that could move three inches away from the mattress; he reported telling a CNA and his daughter about the loose rail about a week earlier. A third resident used bilateral side rails for bed mobility; her right rail could move two to three inches away from the bed, the openings within the rails measured three and one‑half inches wide by 13 inches high, and there was a seven‑inch gap between the foot of her mattress and the footboard. Surveyors also found that the facility’s entrapment assessments and maintenance audits were incomplete or inaccurately documented. Review of the maintenance logbook for side rail inspections from January through April showed that only zone 1 (the opening within the side rail) was consistently assessed, while the other six FDA‑defined entrapment zones were often marked as not applicable, including zone 7 (the space between the mattress and headboard or footboard) even for residents without bed rails. In some months, all seven zones were documented as not applicable for numerous residents known to have side rails, and some residents with side rails were not included in the audits at all. The DON was unsure if there was a specific entrapment assessment policy and believed maintenance handled these assessments, while also acknowledging missing documentation for side rail assessments, consents, and physician orders, and that some side rails were installed without proper documentation. Additional deficiencies related to accident prevention and supervision were identified in several facility‑reported incidents. One resident with a history of stroke and left‑sided weakness fell from his bed while trying to remove his socks after a CNA left his bed at waist height; his care plan at that time did not specify a required bed height, and he was later diagnosed with a minor closed head injury and abrasions. Another resident, care planned to require two staff for transfers and use of a sit‑to‑stand lift, was transferred by a single contracted CNA using a sling that was too small and the wrong hook, causing back pain; the resident and his family reported that he was often transferred by only one staff member despite the care plan. A cognitively impaired resident at risk for elopement exited through a door whose alarm had been deactivated during daytime hours so visitors could enter and exit, walked outside in very cold weather, and re‑entered through another door after about 15 minutes. A further resident, on anticoagulant therapy, fell while transferring herself to the bathroom and hit her head; she had fallen 11 times in 30 days, and the provider failed to implement, review, and revise interventions to reduce her fall risk. These events collectively demonstrate failures to follow care plans, maintain environmental safety devices such as alarms and bed systems, and provide adequate supervision to prevent accidents. The surveyors determined that these failures, particularly the unsecured side rails and unassessed mattress gaps, created a risk for entrapment injury or harm and issued an Immediate Jeopardy finding under F689 related to accident hazards and supervision. Observations throughout the building confirmed multiple safety concerns with side rail installation, maintenance, and bed zone assessments, including loose rails and significant gaps between mattresses and headboards or footboards. Facility leadership and maintenance staff acknowledged that gaps between mattresses and bed ends and loose side rails posed a risk for entrapment and injury, and that entrapment zone measurements and assessments had not been consistently completed according to FDA guidance and facility policy.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Honor Resident Bathing and Undressing Preferences
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity, respect, and self-determination regarding bathing and undressing practices. One resident reported in a facility reported incident that on his bath days, a CNA undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his stated preference to undress in the shower room. During a later interview, this resident stated that the CNA continued this practice, that it made him uncomfortable, and that it happened all the time. The DON stated that the bathing protocol was to follow each resident’s preference for where to undress, and that the CNA had been informed of this resident’s preference. The resident’s care plan documented his need for assistance with dressing but did not include his specific bathing or undressing location preferences. Additional interviews showed that this practice extended to other residents and was not individualized based on resident choice. The CNA acknowledged awareness of the resident’s preference but stated that all residents were undressed in the shower room, while another CNA described a typical routine in which residents with limited mobility who required a mechanical lift were undressed in their rooms, covered with a blanket, and then transported to the shower room. Another resident reported seeing the first resident transported to the shower room covered only by a blanket and stated that the CNA did not ask where he preferred to undress, instead beginning to undress him after announcing it was time for a bath. A third resident stated that the same CNA transferred him from bed to a chair, covered him with a white sheet, and took him to the tub room without asking his preferences, and that he had seen other residents transported in the same manner. These practices conflicted with the facility’s Resident Dignity & Privacy Policy, which required staff to groom and dress residents according to their preferences and to maintain privacy during care.
Failure to Timely Report and Investigate Allegations of Sexual and Financial Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and initiate required investigations into two separate allegations of abuse, including sexual and possible financial abuse. One resident reported that at approximately 6:00 a.m. a contracted travel CNA placed hands down his pants while he was in bed, allegedly to check if he was wet, which the resident described as groping that made him feel cheap. The resident stated he typically did not receive nighttime incontinence checks, as he used a urinal and was usually only awakened for early morning blood sugar checks or lab draws. He reported this incident to two RNs, one of whom acknowledged that it was not appropriate for staff to put their hands down a resident’s pants to check incontinence products. Despite this, the nurses who received the allegation did not immediately report it to the DON, administrator, or state agency as required by facility policy and federal guidelines. One RN spoke with the contracted travel CNA to “educate” her but did not notify anyone else and did not know the required reporting time frame. Another RN, who was aware of the process and the two-hour reporting requirement to the state health department, also failed to promptly report the allegation to the DON or administrator, resulting in a delay until late morning before leadership became aware. At the time leadership was notified, the allegation had not yet been investigated, and law enforcement and the ombudsman had not been contacted, even though the allegation involved possible sexual abuse. A second deficiency arose when a resident’s family member reported concerns of suspected financial abuse to the social services designee, who then informed the administrator. Instead of treating this as an abuse allegation requiring reporting and investigation under the facility’s abuse and neglect policy, the administrator did not report it to the state health department, citing a lack of detailed information. The social services designee and administrator only provided the family with contact information for external agencies such as the state’s attorney and adult protective services. The facility’s own policy required that all allegations and suspicions of abuse, including misappropriation of property and exploitation, be immediately reported to the administrator or designee, investigated by the administrator or designee, and reported to the state agency within two hours, but these procedures were not followed for either the sexual abuse allegation or the suspected financial abuse concern.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
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