Diamond Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgewater, South Dakota.
- Location
- 901 N Main Ave, Bridgewater, South Dakota 57319
- CMS Provider Number
- 435114
- Inspections on file
- 17
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Diamond Care Center during CMS and state inspections, most recent first.
A facility failed to protect a resident from potential abuse by another resident and did not provide timely care for a resident with pressure ulcers. An incident involved a resident found with her blouse unbuttoned in another resident's room, and the facility delayed notifying authorities. Additionally, a hospice resident developed pressure ulcers that were not treated promptly, leading to further deterioration.
Two residents in hospice care developed and worsened pressure ulcers due to the facility's failure to provide timely and necessary care. Despite hospice recommendations and the provision of dressings, the facility staff did not apply them, leading to multiple pressure wounds for one resident. The second resident developed seven pressure ulcers, with some worsening, due to inadequate repositioning and care planning. Communication issues and poor adherence to care practices were noted.
The facility failed to have an RN on duty for eight consecutive hours per day for 37 days across two fiscal quarters and one day in June 2024. Despite being licensed for skilled nursing care, the facility did not meet staffing requirements and relied on phone availability of RNs and physicians. Staffing was based on resident numbers and acuity, and the facility was actively recruiting RNs.
The provider's Arbitration Agreement lacked essential details, such as the full name and contact information of the arbitration organization, and allowed the provider to choose the arbitration location unilaterally. Interviews revealed that staff were unaware of who developed the agreement, and the administrator acknowledged these deficiencies. Despite this, 26 out of 34 residents had signed the agreement, and no disputes had occurred.
The facility failed to submit accurate PBJ data for two fiscal quarters, resulting in deficiencies such as no RN hours for eight consecutive hours each day for more than four days and no 24-hour nurse coverage for more than four days. The administrator confirmed inaccuracies in the data submission and acknowledged the absence of an RN for the required hours, although a licensed nurse was present 24 hours each day.
The facility failed to update and revise care plans for several residents, leading to discrepancies between documented care needs and actual requirements. For example, a resident's fluid restriction was not updated after being discontinued, and another resident's smoking safety was inaccurately documented. Additionally, fall risk interventions were not properly reflected in a resident's care plan, and new safety interventions for vulnerable adults were not included. The MDS/RN was responsible for ensuring care plan accuracy, but this was not consistently achieved.
The facility failed to monitor and remove expired medications and personal care products. Expired PRN medications for three residents were found in a medication cart, and four medications lacked opened or expiration date stickers. Additionally, prescription personal care products in a tub room were not securely stored or discarded when expired. The facility's policy on medication storage and expiration monitoring was not followed.
A registered nurse failed to follow infection control practices during dressing changes for two residents on enhanced barrier precautions. The nurse did not perform hand hygiene at critical points, used the same gloves for multiple tasks, and directly touched residents' wounds without proper glove changes. Despite receiving training, the nurse was unaware of the missed opportunities for hand hygiene, contrary to the facility's policies.
Two residents were not routinely assessed for safe self-administration of medications, despite having intact cognition and orders for self-administration. One resident had a nasal spray without a self-administration order, and the other had not been assessed for over a year. The facility's policy required quarterly assessments, which were not conducted.
A provider failed to accurately code MDS assessments for two residents, leading to documentation errors. One resident's pressure ulcers were not recorded in the MDS, and another resident was incorrectly noted to have a catheter. The MDS/RN responsible did not review necessary documentation or was unaware of the errors, relying on basic training and the RAI manual for guidance.
A resident receiving dialysis twice weekly was not properly monitored for vital signs and fistula site abnormalities upon returning from treatment on four occasions. The charge nurse was responsible for this task, but documentation was missing, particularly on days when an LPN with known documentation issues was on duty. The facility's policy required such monitoring and reporting of concerns to medical professionals.
The facility failed to properly assess and document the use of bed side rails for two residents. One resident used side rails for turning after a hip fracture, but documentation inconsistencies were noted between physician orders and evaluations. Another resident had a side rail for repositioning, but assessments were not updated as required. The facility's policy mandated quarterly assessments, which were not completed, and the MDS coordinator was unaware of the oversight.
Failure to Protect Resident from Abuse and Neglect and Inadequate Pressure Ulcer Care
Penalty
Summary
The provider failed to protect a resident who was mentally incapable of identifying safety risks from potential abuse and neglect by another resident. An incident occurred where a resident was found in another resident's room with her blouse unbuttoned and her breasts exposed. The resident was unable to unbutton her shirt herself due to a physical disability, raising concerns about inappropriate behavior. The facility did not notify law enforcement or the Department of Human Services immediately, as required, and waited for guidance from the South Dakota Department of Health. Additionally, the provider failed to provide necessary care for a resident with pressure ulcers. The resident, who was on hospice care, developed multiple pressure ulcers on her buttocks and heel. Despite the availability of dressings provided by hospice, the facility staff did not apply them in a timely manner, leading to the deterioration of the resident's condition. The pressure ulcers were not documented or treated appropriately until several days after they were first identified. The facility's inaction in both cases highlights a lack of adherence to protocols for reporting and addressing potential abuse and neglect, as well as a failure to provide timely and adequate care for pressure ulcers. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The provider failed to ensure timely and necessary care for two residents, leading to the development and worsening of pressure ulcers. For the first resident, hospice staff identified reddened areas on the buttocks on June 6, 2024, and provided dressings on June 7, 2024. However, the facility staff did not apply these dressings and instead placed the resident in a wheelchair, applying only cream. By June 10, 2024, the resident's condition had worsened, with multiple pressure wounds identified, including on the buttocks, coccyx, and heel. The family was not informed until June 10, 2024, and the appropriate wound care orders were not documented as completed until June 12, 2024. The resident passed away on June 14, 2024. The second resident, who was also under hospice care, developed multiple pressure ulcers while in the facility's care. Despite being at high risk for skin breakdown, as indicated by fluctuating Braden scores, there was a lack of documentation and implementation of a comprehensive repositioning plan. The resident acquired seven pressure ulcers, with some worsening from stage 2 to stage 3. The facility's documentation was inconsistent, and there was a delay in updating care plans to reflect the resident's declining condition and the need for pressure-relieving interventions. Interviews with hospice staff and facility personnel revealed communication issues and a lack of adherence to recommended care practices. Hospice staff expressed concerns about the facility's management of pressure ulcer care, noting that recommendations were not followed, and there was poor communication between the hospice agency and the facility. The facility's policies on pressure ulcer prevention and care planning were not effectively implemented, contributing to the deficiencies observed.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours per day for a total of 37 days across Federal Fiscal Quarters 1 and 2, as well as one day in June 2024. This deficiency was identified through a review of Payroll Based Journal (PBJ) reports, interviews, and record reviews. The specific dates without adequate RN coverage were detailed in the report, spanning multiple months from October 2023 to March 2024, and included an additional day in June 2024. The facility did not have a nurse waiver and was licensed to provide skilled nursing care, yet failed to meet the staffing requirement. Interviews with the facility's administrator and the Minimum Data Set (MDS) coordinator revealed that the PBJ data was entered manually, and there were issues accessing reports online. The administrator confirmed the absence of an RN for the required hours on the specified days and noted that while an RN was not always present, a physician and an RN were available by phone. The facility was actively advertising for RN positions through various channels, and staffing decisions were based on resident numbers and acuity levels. However, the facility did not have residents requiring RN care at the time of the deficiency.
Deficiency in Arbitration Agreement Details
Penalty
Summary
The provider failed to ensure that their Arbitration Agreement included the necessary details for a fair arbitration process. The agreement did not specify the full name of the arbitration organization or provide contact information for it. Additionally, the agreement allowed the provider to unilaterally select the location for arbitration, rather than ensuring it was convenient for both parties involved. Interviews with the administrator and the business office/social service designee revealed that they were unaware of who developed or approved the agreement, and that the agreement's deficiencies were not recognized until the survey. The administrator acknowledged that the agreement should have included the arbitration agency's full name and contact information, and that the location for arbitration should not be solely determined by the provider. It was also noted that not all residents had signed the arbitration agreement, and the administrator was unsure why some had not. Despite these issues, no disputes had occurred to date. A review of the provider's records showed that 26 out of 34 current residents had signed the Arbitration Agreement.
Inaccurate PBJ Data Submission and Staffing Deficiencies
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for Federal Fiscal Quarters 1 and 2. The PBJ CASPER reports indicated that there were no registered nurse (RN) hours for eight consecutive hours each day for more than four days, and no 24-hour nurse coverage each day for more than four days. Additionally, the weekend staffing metric was suppressed due to excessively low data submission. The administrator confirmed that the data for these quarters had not been submitted accurately, and there was no nurse waiver in place. Interviews revealed that the Minimum Data Set Coordinator (MDS)/RN was responsible for submitting the PBJ data until January 1, 2024, after which the administrator took over. The facility's time clock system did not automatically upload payroll data to the PBJ system, requiring manual entry. The administrator acknowledged that there was not always an RN present for eight consecutive hours each day, although a licensed nurse was present 24 hours each day. The administrator also declined to answer questions regarding the accuracy of low weekend staffing data.
Failure to Update and Revise Care Plans
Penalty
Summary
The provider failed to review and revise comprehensive care plans for six of twelve sampled residents, leading to discrepancies between the care plans and the actual care needs of the residents. For instance, a resident receiving dialysis treatments had a care plan indicating fluid restrictions, which were no longer applicable as the dialysis provider had discontinued them. This discrepancy was not communicated effectively to the staff, resulting in confusion about the resident's current care needs. Another resident, who smoked cigarettes, was assessed as safe to smoke independently, but the care plan inaccurately indicated that he was not safe to smoke on his own. This inconsistency in the care plan could lead to inappropriate supervision and care. Additionally, a resident with a high risk of falls had a care plan that did not reflect the necessary interventions, such as positioning the bed low to the floor and using a fall mat at night, which were crucial for her safety. Furthermore, the care plans for two residents who were considered vulnerable adults due to their conditions were not updated to include new interventions for their safety. The facility's policy required care plans to be updated with any significant changes in the resident's condition, but this was not consistently done. The MDS/RN was responsible for ensuring the accuracy of the care plans, but the documentation did not support that the care plans were updated as required.
Expired Medications and Improper Storage in Facility
Penalty
Summary
The provider failed to ensure proper monitoring and removal of expired medications and personal care products in the facility. During an observation, it was found that PRN medications stored in blister pack cards for three residents were expired and had not been removed for destruction. Additionally, four medications for three residents lacked opened or expiration date stickers. The facility's policy requires that expiration dates be determined by the pharmacist at dispensing and that medications be marked with an opened date. However, these procedures were not followed, leading to expired medications remaining in the medication cart. In a separate observation, prescription personal care products in a resident tub room were not securely stored or discarded when expired. The tub room contained prescription products with expired dates, including Selsun Blue shampoo, anti-itch lotion, Desitin, and Nystatin powder. The MDS coordinator/RN confirmed that prescription items should have been stored in a locked medication cart or room and that expiration dates should have been monitored and expired items discarded. However, these practices were not adhered to, resulting in expired and improperly stored prescription products in the tub room.
Infection Control Deficiency During Dressing Changes
Penalty
Summary
The provider failed to adhere to acceptable infection control practices during dressing changes for two residents, both of whom were on enhanced barrier precautions (EBP). Registered Nurse (RN) N was observed performing dressing changes for these residents without following proper hand hygiene protocols. During the dressing change for the first resident, RN N donned gloves and a gown in the hallway, then proceeded to touch various surfaces and the resident's personal items without changing gloves or performing hand hygiene. She also touched the resident's wound area directly with gloved hands that had been in contact with potentially contaminated surfaces. After removing her gloves, she did not wash her hands before applying tape to the gauze and the resident's toe, which is considered hands-on care. In a similar incident with the second resident, RN N again failed to perform hand hygiene at critical points during the dressing change. She used the same pair of gloves to handle supplies, touch the resident's skin, and apply wound care products. After removing her gloves, she did not wash her hands before securing the dressing with tape, directly touching the resident's toe. These actions were contrary to the facility's hand hygiene and personal protective equipment policies, which require hand hygiene before and after resident care and the use of gloves. Interviews with RN N revealed a lack of awareness regarding the missed opportunities for hand hygiene and glove changes. Despite receiving ongoing training from her staffing agency, RN N did not follow the facility's infection control policies. The Minimum Data Set (MDS) coordinator confirmed that agency staff were expected to adhere to the facility's policies, although orientation did not cover handwashing or glove use. The facility's policies clearly outlined the need for hand hygiene and proper use of personal protective equipment, which were not followed in these instances.
Failure to Routinely Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as residents 8 and 9, were routinely assessed for the safe self-administration of medications. During an interview and observation, it was noted that resident 8 had a bottle of nasal spray on her bedside table, but the registered nurse (RN) was unsure if there was a physician order for self-administration, leading her to administer the medication herself. Resident 8's medical record indicated she had a BIMS score of 15, showing intact cognition, and had several medications she was allowed to self-administer, but there was no self-administration order for the nasal spray. Resident 9 also had a BIMS score of 15, indicating intact cognition, and had an order for unsupervised self-administration of a medication for constipation. However, her most recent self-administration assessment was completed over a year ago. The facility's policy required quarterly assessments for self-administration, which were not conducted for either resident. The minimum data set coordinator confirmed that these assessments should have been completed quarterly. The facility's policy on self-administration of medications outlined the need for an initial screening tool to evaluate residents' ability to self-administer medications, with quarterly evaluations thereafter. Despite this policy, the facility did not perform the required quarterly assessments for residents 8 and 9, leading to a deficiency in ensuring the safe self-administration of medications.
Inaccurate MDS Assessments for Pressure Ulcers and Catheter Use
Penalty
Summary
The provider failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical conditions. For one resident with pressure ulcers, the MDS assessment completed on 5/11/2024 inaccurately indicated that the resident had no unhealed pressure ulcers, despite weekly wound documentation on 5/6/2024 showing two grade 2 coccyx pressure wounds. The MDS/registered nurse (RN) responsible for the assessment admitted to not reviewing the weekly wound documentation before completing the MDS, resulting in incorrect coding. In another case, a resident's MDS assessment on 5/4/2024 incorrectly noted the presence of an indwelling urinary catheter, although the resident had not had a catheter since admission. The MDS/RN responsible for this assessment was unaware that the section had been marked incorrectly. The RN's training included basic online resources, and she relied on the RAI manual for guidance when needed. These inaccuracies highlight a failure to adhere to the CMS Resident Assessment Instrument (RAI) Manual guidelines, which require thorough review and confirmation of medical records and resident conditions.
Failure to Monitor Dialysis Patient Post-Treatment
Penalty
Summary
The provider failed to ensure proper monitoring of a resident who required dialysis treatment. Resident 16, who received dialysis twice a week, had a physician's order dated December 4, 2023, which required the assessment of vital signs and the fistula site for any abnormalities upon returning from dialysis. This assessment was to be documented, and any abnormal findings were to be reported to the primary care provider. However, there was no documentation of such monitoring for four out of sixteen opportunities between April 19, 2024, and June 10, 2024. The specific dates lacking documentation were April 19, May 13, May 20, and June 10, 2024. Interviews revealed that the charge nurse on duty was responsible for monitoring and documenting the resident's condition in the electronic medical record. The minimum data set coordinator/registered nurse indicated that LPN J was responsible for the documentation on three of the four days it was not completed. However, LPN J's documentation had been problematic, and she was no longer employed at the facility. The provider's dialysis policy, dated October 29, 2024, stated that nurses should monitor the dialysis catheter and/or AV fistula site every shift for signs of infection or malfunction, and report any concerns to the appropriate medical professionals.
Failure to Assess and Document Bed Side Rail Use
Penalty
Summary
The facility failed to ensure that two residents using bed side rails were appropriately assessed, and the documentation accurately reflected the type of bed side rail in use. Resident 8 was observed using side rails on both sides of the upper half of her bed, which she had been using since 2023 to assist with turning in bed after a hip fracture. Her medical record indicated a physician's order for a 1/4 side rail/grab bar, but the Physical Device Evaluation noted the use of 1/2 side rails. No further evaluations were completed after April 2023, and her care plan mentioned the use of a 1/4 side rail/grab bar, indicating inconsistencies in documentation and assessment. Resident 2 was observed with a side rail on the right side of his bed, with a physician's order for a U-shaped grab or 1/4 side rail to assist with independence and repositioning. An Assistive Device Assessment and a Physical Device Assessment were completed in January 2024, but no further assessments were conducted. The facility's policy required quarterly assessments for side rail use, which were not completed for these residents. The MDS coordinator acknowledged the lack of current assessments and was unsure why they were not completed. The facility's restraint policy outlined the need for assessments and care plan reviews, which were not adhered to in these cases.
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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