Firesteel Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mitchell, South Dakota.
- Location
- 1120 East 7th Avenue, Mitchell, South Dakota 57301
- CMS Provider Number
- 435109
- Inspections on file
- 29
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Firesteel Healthcare Center during CMS and state inspections, most recent first.
Staff did not provide required supervision or follow care plan interventions for two residents, resulting in one resident with severe cognitive impairment and aspiration risk being left unsupervised in the dining room and sustaining multiple facial fractures after a fall, and another resident with Parkinson's disease falling during a transfer when only one CNA assisted with a sit-to-stand lift instead of the required two staff members.
A resident with a history of depression and prior suicidal ideations was admitted after a hospital stay with psychiatric recommendations for 24-hour supervision and increased monitoring. The facility did not implement increased supervision, update the care plan to reflect current suicidal risk, or notify the primary care provider after the resident expressed suicidal ideations. The resident was not seen again by mental health services after the initial evaluation, and staff failed to follow professional standards for suicide risk. The resident ultimately died by suicide, which was discovered by a CNA during routine rounds.
A resident with severe cognitive impairment and multiple neurological diagnoses was not consistently provided with a physician-ordered palm protector for contracture management. Despite documentation indicating the device was applied, observations showed the resident's hand was tightly contracted without the protector in place. Staff interviews revealed inconsistent application and lack of verification checks after transfers and meals, and no policy on following physician's orders was provided.
Staff failed to consistently perform hand hygiene and use appropriate PPE during resident care and meal assistance, did not properly implement or discontinue contact precautions, and neglected to clean shared equipment, all during a norovirus outbreak that affected many residents and resulted in hospitalizations.
A resident experienced a persistent infestation of flying ants in their room, reporting daily encounters and multiple bites, with visible evidence of ants and bites confirmed by staff and surveyors. Despite repeated cleaning, placement of ant bait, and pest control company visits, the problem continued for several weeks, indicating a failure to maintain an environment free of pests as required by facility policy.
Surveyors found that prepared foods were stored uncovered and ready-to-eat salad was placed below raw bacon in the walk-in cooler, creating a risk for cross-contamination. Egg salad sandwiches and bowls, considered potentially hazardous foods, were served to residents at temperatures above the required 41°F, with no documentation of temperature checks prior to service. Staff and management acknowledged these failures, which did not align with facility policies or professional food safety standards.
Persistent sewer and urine odors were present in multiple facility areas, including the therapy gym and a hallway near the nurse's station. A resident reported the sewer odor had been an ongoing issue, and staff confirmed repeated but unsuccessful attempts to resolve it. Another resident's room and the surrounding hallway had a strong urine smell due to incontinence and resistance to cleaning, with odors persisting despite deep cleaning efforts. These conditions resulted in an environment that was not safe, clean, or homelike.
Three residents' care plans were not updated to reflect their current needs, including a resident with PTSD whose trauma history and use of a foot cradle were omitted, a resident whose dietary preferences and use of a water bladder were not documented, and a resident whose care plan listed a resolved wound but failed to include current venous stasis ulcers and Unna boot treatment. Staff were often unaware of these omissions, and the facility did not provide a care plan policy during the survey.
Two residents and their representatives did not fully understand the binding arbitration agreement process during admission, with one agreement lacking clear documentation of acceptance or declination and both parties later reporting they were unaware that signing the agreement waived their right to legal action. Both residents were cognitively intact at the time, and the facility's process for explaining the agreement was found to be insufficient in ensuring informed consent.
The facility did not implement or document effective QAPI actions to address ongoing deficiencies in hand hygiene and PPE compliance, as repeated audits showed compliance rates below benchmarks and only staff education was used as a corrective measure. This inaction coincided with an outbreak of gastrointestinal illness affecting several residents and staff.
Two residents were allowed to self-administer nebulizer medications without required assessments, physician orders, or care plan documentation. Staff set up the treatments and left the residents unsupervised, contrary to facility policy, which mandates evaluation and authorization before permitting self-administration.
A resident identified as an elopement risk left the facility without staff knowledge when a door alarm was triggered. Staff failed to respond appropriately, as neither a CNA nor an RN checked outside the door after the alarm sounded. The resident was later found by a police officer and returned to the facility.
A resident in a LTC facility experienced a deficiency in safe transfer practices using a sit-to-stand lift. The resident, who required assistance from two staff members, was not properly secured during a transfer, leading to a fall. Staff interviews revealed inconsistencies in lift use and care plan adherence, while maintenance issues with the lifts, such as missing clips, were not promptly addressed.
A facility failed to follow prescribed renal and cardiac therapeutic diets during a supper service, affecting residents who required specific dietary accommodations. A cook served the same meal to all residents, overlooking the therapeutic diet spreadsheets due to inadequate training. The Diet Order Tally Record was outdated, and some residents had not signed risk/benefit forms to decline therapeutic diets.
A CNA took a photo of a resident's head injury without permission, violating privacy rights. The resident, who was severely cognitively impaired and in hospice care, had fallen and sustained a head injury. The CNA, concerned about the resident's condition, took the photo but did not share it. The CNA was agency staff and had completed HIPAA training.
The facility failed to monitor neurological changes in five residents after falls. A resident on hospice care and another with cardiac issues did not receive required neurological evaluations post-fall. The DON acknowledged the lapse in following the facility's policy, which mandates evaluations for 72 hours after an unwitnessed fall or head injury.
A resident with cognitive impairment spilled coffee on herself due to the facility's failure to conduct a hot liquid assessment at admission. The facility also lacked consistent temperature monitoring of hot beverages, as required by policy, leading to a deficiency in ensuring resident safety.
A resident with moderate cognitive impairment was readmitted to a facility with a clostridium difficile diagnosis and an order for Vancomycin. The admitting team incorrectly entered the antibiotic order as unsupervised medication administration, leading to the resident missing 16 doses. Despite this, nurses charted no adverse side effects. The error was discovered after the resident was readmitted to the hospital for hyponatremia and hyperglycemia. Staff interviews revealed a lack of awareness and communication regarding the medication order error.
A resident fell from a mechanical lift due to the use of an incorrectly sized sling, resulting in a hip fracture and hospitalization. The resident, who was cognitively intact and had multiple health conditions, became unbalanced during the transfer. Staff interviews revealed that the sling used was too large, and the RN confirmed it was placed incorrectly, leading to the fall.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights for several residents. Observations and interviews revealed that residents experienced long wait times for assistance, particularly those requiring mechanical lifts for transfers. Staff shortages and the lack of specific policies for call light response times contributed to the inconsistency in care delivery.
A resident with multiple health conditions, including low potassium levels, did not receive prescribed doses of folic acid and potassium chloride after being admitted to the facility. The medication errors were due to issues with the electronic medical record system and lack of proper double-checking and confirmation of orders, leading to the resident's hospitalization for low potassium levels and other complications.
The provider failed to ensure that two residents who smoked were assessed for safety. One resident, at risk for elopement, was allowed to go outside independently due to a miscommunication, and another resident was not aware of any designated smoking area and had not been assessed for smoking safety. The facility's smoking safety policies were not followed.
Failure to Provide Supervision and Follow Care Plans Leads to Resident Falls
Penalty
Summary
Staff failed to provide adequate supervision and accident prevention interventions as outlined in residents' care plans, resulting in two separate incidents involving falls. In one case, a resident with severe cognitive impairment, repeated falls, progressive supranuclear ophthalmoplegia, dementia, and a history of aspiration risk was left unsupervised in the dining room. Despite multiple prior falls in the same location and care plan interventions specifying that the resident should not be left alone, staff left the resident unattended while assisting others. The resident was subsequently found face down on the floor with significant facial injuries, including multiple facial fractures and a comminuted nasal bone fracture. The care plan had been updated after previous incidents to require supervision in the dining room, but this intervention was not followed at the time of the fall. Interviews with staff revealed that the staff member assigned to supervise the dining room did not remain with the resident as required, citing competing care needs elsewhere in the facility. The daily staffing assignment sheet identified who was responsible for dining room supervision, but staff often did not adhere to these assignments. The medication aide and nurse confirmed that the resident should not have been left unsupervised, especially given his swallowing difficulties and risk for aspiration. The director of nursing acknowledged that the care plan intervention for dining room supervision was not followed at the time of the incident. In a separate incident, another resident with Parkinson's disease, weakness, and abnormal gait was being transferred using a sit-to-stand mechanical lift. The care plan specified that two staff members were required for transfers with this device due to the resident's instability. However, only one CNA performed the transfer, and the resident's hands slipped from the handlebars, resulting in a fall to the floor. The CNA was unaware of the updated care plan requirement for two-person assistance. Both the nurse and the CNA confirmed that the care plan was not followed, and the director of nursing agreed that this failure placed the resident's safety at risk.
Failure to Provide Necessary Behavioral Health Services Resulting in Resident Suicide
Penalty
Summary
A facility failed to provide necessary behavioral health care and services to a resident with a diagnosed serious mental illness, resulting in the resident's suicide. The resident had a history of depression, prior suicidal ideations, and was admitted to the facility following a hospital stay where psychiatry had recommended 24-hour supervision, psychiatric medication management, and increased monitoring due to high suicide risk. Despite these recommendations, the facility did not implement increased supervision or update the resident's care plan to reflect active suicidal ideations and necessary interventions. The resident's care plan only indicated a history of suicidal ideations, not current risk, and staff were not instructed to monitor the resident more closely or search for means of self-harm in the resident's room. Documentation in the resident's medical record showed that after expressing suicidal ideations to a family member, there was no follow-up assessment or increased monitoring by staff. The primary care provider was not notified of the resident's suicidal statements, and there was no evidence of ongoing psychiatric follow-up or consistent behavioral health services after the initial mental health visit. The contracted mental health service did not have a routine schedule for seeing residents, and the resident was not seen again after the initial evaluation. Staff interviews revealed a lack of awareness regarding the seriousness of the resident's suicidal ideations and a failure to communicate critical information among the care team. The facility's own reference materials and professional standards outlined the need for close observation, psychiatric referral, and crisis intervention for residents with depression and suicidal ideations. However, these standards were not followed, as evidenced by the absence of increased supervision, lack of care plan updates, and failure to notify the primary care provider or implement safety interventions. The resident ultimately committed suicide in his room, and the incident was discovered by a CNA during routine rounds.
Failure to Ensure Physician-Ordered Palm Protector Applied for Contracture Management
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple complex diagnoses, including ataxia, stiff-man syndrome, dementia, mood disorder, weakness, repeated falls, malignant neoplasm of the brain, and epilepsy, was not provided with a palm protector as ordered by the physician for contracture management of his right hand. Observations on two consecutive days revealed the resident's right hand was tightly curled with fingers digging into the palm, and no palm protector was in place. The resident stated he only wore the device when working, and a newly hired CNA reported never seeing the resident wear the palm protector. Documentation in the electronic medical record indicated the device was applied, but direct observation contradicted this. Further interviews with staff revealed that while there were instructions and documentation processes in place for the application of the palm protector, there were no scheduled verification checks after transfers or meals to ensure the device was reapplied as required. The facility was unable to provide a policy regarding following physician's orders during the survey. These actions and inactions led to the failure to ensure the resident consistently received the prescribed contracture management intervention.
Failure to Follow Infection Control Practices During Norovirus Outbreak
Penalty
Summary
Staff at the facility failed to adhere to proper infection prevention and control practices, particularly regarding hand hygiene and the use of personal protective equipment (PPE). During multiple observations, staff members did not perform hand hygiene at critical points, such as after removing gloves, after touching potentially contaminated surfaces, or before assisting residents with eating. For example, two CNAs were observed changing a resident's soiled brief, touching various items in the resident's environment with contaminated gloves, and then failing to perform hand hygiene after glove removal. Additionally, staff were seen assisting residents with eating and handling food items without sanitizing their hands, even after touching their own hair or after coughing into their hands. The facility also failed to ensure proper implementation and discontinuation of contact precautions for residents with gastrointestinal (GI) symptoms. Staff did not consistently wear required PPE, such as gowns and gloves, when providing care to residents on contact precautions. In one instance, staff were unaware of which resident in a shared room was on contact precautions and did not follow posted signage or use appropriate PPE. Equipment such as full body lifts was not cleaned between uses, and contact precaution signage and supplies were not promptly removed or updated when precautions were discontinued. These lapses in infection control practices occurred during a facility-wide norovirus outbreak, which affected at least 45 residents with confirmed or suspected GI symptoms. The outbreak led to hospitalizations, including one resident who was admitted to the ICU. The facility's own policies required regular staff training, proper hand hygiene, and adherence to transmission-based precautions, but these were not consistently followed as evidenced by direct observations, interviews, and record reviews.
Failure to Ensure Effective Pest Control for Flying Ants
Penalty
Summary
The facility failed to ensure effective pest control for flying ants in the room of one resident who repeatedly reported and demonstrated the presence of flying ants and ant bites. The resident stated that he experienced a daily problem with flying ants, killing 30 to 40 each day, and reported being bitten multiple times, with visible red marks on his back. Observations confirmed the presence of dead and live flying ants on the resident's nightstand, bed, and window screen over several days. The resident also reported that the problem had persisted for several weeks, and maintenance staff believed the ants were entering from behind the heater below the window. Documentation and interviews revealed that the facility was aware of the issue as early as 4/11/25, when a work order was created in the maintenance system. Staff responded by deep cleaning the room, placing ant bait, and spraying ant killer outside the affected area. Despite these actions, the flying ant problem continued, as evidenced by ongoing resident complaints and direct observations of ants in the room. The pest control company had provided regular monthly services and an extra visit in March, but there was no documentation of additional targeted pest control interventions after the problem was reported in April. The facility's pest control policy required prompt reporting and additional pest control visits when a problem was detected. However, records showed that after the initial reports and interventions, the flying ant infestation persisted in the resident's room, with no evidence of further pest control company involvement or effective resolution. The ongoing presence of flying ants and the resident's continued exposure to bites indicated a failure to maintain an environment free of pests as required by facility policy.
Improper Food Storage and Temperature Control in Kitchen
Penalty
Summary
Surveyors identified multiple failures in food safety practices within the facility's kitchen, specifically related to the storage, preparation, and serving of food. Observations revealed that prepared foods, such as individual servings of chocolate pudding and uncooked pizzas, were stored uncovered in the walk-in cooler, leaving them exposed to air. Additionally, a ready-to-eat salad was stored on the bottom shelf directly underneath a cardboard box of raw bacon strips, which had water on top, creating a risk for cross-contamination. The salad was later served to residents during a meal service. Staff interviews confirmed that the salad had been prepared that day and would be served, and both staff and management acknowledged the improper storage and potential for cross-contamination. Further deficiencies were noted in the handling of potentially hazardous foods (PHF/TCS), specifically egg salad sandwiches and bowls prepared with hard-boiled eggs and mayonnaise. These items were prepared in advance, stored in the walk-in cooler, and served to residents during meal service. Temperature checks conducted by the regional dietitian revealed that the egg salad items were held at temperatures ranging from 50.4 to 53.4 degrees Fahrenheit, which is above the required maximum of 41 degrees Fahrenheit for safe cold holding of PHF/TCS foods. There was no documentation of food temperatures being taken prior to meal service to ensure compliance with food safety standards. Review of facility policies confirmed that raw meats and eggs should not be stored above ready-to-eat foods and that PHF/TCS foods must be cooled and held at or below 41 degrees Fahrenheit. The posted Safe Refrigerator Storage chart in the walk-in cooler was not followed, as evidenced by the improper storage of raw and ready-to-eat foods. Staff and management interviews consistently acknowledged the observed deficiencies and agreed that the practices did not meet the facility's own policies or professional standards for food safety.
Failure to Maintain Odor-Free, Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment free from foul odors in multiple areas, including the physical therapy gym, the nurse's desk outside the therapy gym, the rehab dining room, and the 200-hallway near the nurse's station. Staff and residents reported a persistent sewer odor, particularly near the therapy gym, which was confirmed by both observation and interviews. Maintenance records showed repeated work orders addressing the sewer smell, including smoke tests and plumbing repairs, but the odor continued to be present and noticeable to residents and staff. One resident reported the issue had persisted for years and had communicated concerns to the administrator multiple times, but the problem was not fully resolved. Additionally, a strong urine odor was observed in a resident's room on the 200-hallway and was noticeable down the hall near the nurse's station. The resident was found lying on his bed in wet clothing, with an empty urinal nearby, and did not perceive the odor himself. Staff interviews indicated that the resident often missed the urinal, resulting in urine on the floor and other surfaces, and that he was resistant to having his room cleaned or his linens changed. Housekeeping staff attempted to coordinate cleaning with the resident's bath days, but reported limited cooperation from nursing staff in addressing persistent odor issues. Despite deep cleaning efforts and the use of disinfectant cleaners, the urine odor in the resident's room and the surrounding hallway persisted, sometimes masked by air fresheners. Housekeeping policies required daily damp mopping and thorough cleaning, but the ongoing presence of strong odors indicated that these measures were not effective in eliminating the problem. The facility's failure to address and resolve these odor issues resulted in an environment that was not safe, clean, comfortable, or homelike for residents.
Failure to Update Care Plans for Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated to reflect the current needs and preferences of three residents. For one resident with major depressive disorder and PTSD, the care plan did not include her PTSD diagnosis or interventions to prevent re-traumatization, nor did it mention the use of a foot cradle that had been implemented months prior. Staff members, including CNAs and the MDS coordinator, were unaware of the resident's trauma history, triggers, or the specialized equipment in use, indicating a lack of communication and documentation regarding her psychosocial and physical care needs. Another resident's care plan did not reflect her preference to skip breakfast or her use of a hiking water bladder for fluid intake while in bed, despite staff being aware of these preferences and accommodations. The omission of these details from the care plan meant that her individualized dietary and hydration needs were not formally documented for all staff to follow. The intake team and MDS coordinator typically managed care plan updates, but these specific preferences and equipment were not included. A third resident's care plan listed a resolved surgical wound on the neck but failed to document current venous stasis wounds on both lower legs and the use of Unna boots for treatment. Nursing staff confirmed the presence of these wounds and the ongoing treatment, but the care plan was not updated to reflect the current skin integrity issues or interventions. The facility did not provide a care plan policy during the survey, and staff interviews revealed inconsistent practices regarding the inclusion of wound treatments and specialized equipment in care plans.
Failure to Ensure Informed Consent for Binding Arbitration Agreements
Penalty
Summary
The provider failed to ensure that residents or their representatives fully understood the binding arbitration agreement process during admission. For two of three sampled residents, documentation and interviews revealed that the process for informing and obtaining consent regarding the arbitration agreement was insufficient. One resident's wife signed the agreement but later stated she did not recall what the agreement entailed or that it involved waiving the right to legal litigation in court. She reported feeling overwhelmed during the admission process and did not remember a thorough explanation of the arbitration agreement, indicating she would not have signed had she understood its implications. The resident himself could not recall the agreement or its significance, and expressed frustration upon learning about the waiver of legal rights. Record review showed inconsistencies in the documentation of consent. For one resident, the arbitration agreement form lacked a checkmark indicating acceptance or declination, while another resident's form included a marked acceptance. The facility's social services director acknowledged that the parent company had recently revised the form to include explicit options for acceptance or declination to improve clarity. Despite these changes, interviews indicated that the explanation of the agreement may not have been sufficiently detailed or comprehensible for residents and their representatives at the time of signing. Both residents involved were assessed as cognitively intact according to their Brief Interview for Mental Status (BIMS) scores at the time of admission and subsequent assessments. The facility's process involved the social services director meeting with residents and representatives to review admission paperwork, including the arbitration agreement, and explaining that participation was optional. However, the lack of clear documentation and the residents' and representatives' lack of understanding demonstrated a failure to ensure informed consent regarding the binding arbitration agreement.
Failure to Implement Effective QAPI Actions for Infection Control Deficiencies
Penalty
Summary
The facility failed to identify, implement, and document effective quality assurance and performance improvement (QAPI) plans to address ongoing infection control deficiencies related to hand hygiene and personal protective equipment (PPE) compliance. Over a three-month period, audits consistently showed that staff compliance with hand hygiene and PPE protocols remained below the facility's established benchmarks. Despite monthly QAPI meetings and the identification of these issues, the only action taken was to continue staff education, with no additional interventions or strategies documented to address the persistent non-compliance. Observations and interviews during the survey period revealed that these deficiencies potentially contributed to an outbreak of gastrointestinal illness affecting multiple residents and staff. QAPI records showed inconsistent benchmarks for compliance and repeated documentation of the same issues and corrective actions across several months, with little to no change in outcomes. Meeting notes often left outcome sections blank or repeated previous entries, indicating a lack of effective follow-up or adjustment to the plan of correction.
Failure to Assess and Authorize Self-Administration of Nebulizer Medications
Penalty
Summary
The provider failed to ensure that two residents were properly assessed for their ability to safely self-administer nebulizer medications, as required by facility policy. In the case of one resident with moderate cognitive impairment (BIMS score of 12), staff set up the nebulizer medication and left the resident to self-administer the treatment without remaining in the room or directly supervising the process. There was no physician's order authorizing self-administration, no assessment documenting the resident's capability to self-administer, and the care plan did not reflect self-administration of medications. Staff confirmed that these required steps had not been completed. Similarly, another resident, who was cognitively intact (BIMS score of 15), was observed independently inhaling a nebulizer treatment without staff present. Although the resident had received initial education and supervision, staff subsequently left him alone to complete the treatments. There were no physician's orders, assessments, or care plan documentation supporting his ability to self-administer the nebulizer medication. The facility's policy requires a self-medication evaluation, a physician's order, and care plan updates before allowing residents to self-administer medications, none of which were completed for these residents.
Resident Elopement Due to Inadequate Response to Door Alarm
Penalty
Summary
A resident identified as an elopement risk on admission was not accounted for when a door alarm activated. The incident occurred when the resident left the facility without staff knowledge, and the door alarm was triggered. The resident was later found by a city policeman and a maintenance supervisor and was brought back to the facility. At the time of the incident, the resident had a Wander Guard in place, which was supposed to activate the door alarm, and her medical record indicated severe cognitive impairment. The facility's staff failed to respond appropriately to the door alarm. A certified nursing assistant (CNA) noticed the alarm and the blinking red light above the emergency exit doors but did not open the door or look out the window to check if someone had left. The CNA reported the alarm to a registered nurse (RN), who also failed to visually check outside the door after silencing the alarm. The RN's employment was terminated following the incident. The facility had video surveillance cameras on some entrance/exit doors, but the door alarm panel for the 400 hall, where the incident occurred, was not yet installed. The executive director confirmed that neither the CNA nor the RN visually checked outside the door to see if someone had left the facility. The resident was eventually found outside by a police officer, who was informed by the maintenance supervisor that the resident belonged to the facility.
Deficiency in Safe Transfer Practices Using Sit-to-Stand Lifts
Penalty
Summary
The deficiency involved a failure to ensure the safety of a resident during transfers using a sit-to-stand lift. The resident, who was cognitively intact and weighed between 366 and 375 pounds, required assistance from two staff members for transfers. However, during a transfer from the commode to a recliner, the safety strap of the sling was not adjusted, and the resident had to be lowered to the floor. The incident occurred when a CNA attempted to transfer the resident alone, without fastening the leg strap or ensuring the mid-body lift sling strap was tightened. Interviews with staff revealed inconsistencies in the use of mechanical lifts, with some staff not adhering to the care plan or special instructions for each resident. The care plan for the resident in question was not updated to reflect changes in transfer methods, and there was confusion among staff regarding which lift and sling to use. Additionally, some lifts were reported to lower residents unexpectedly, and several lifts were found to be missing necessary clips for safe operation. The facility's maintenance procedures were also called into question, as missing parts on the lifts were not reported or addressed in a timely manner. The maintenance supervisor was unaware of the missing clips and had not been notified of any mechanical issues through the facility's electronic work order system. Despite monthly inspections, the deficiencies in the lifts' condition and the lack of proper staff notification contributed to the unsafe transfer conditions for the resident.
Failure to Follow Therapeutic Diets
Penalty
Summary
The facility failed to adhere to the planned menu for residents on renal and cardiac therapeutic diets, as observed during a supper service. A resident, who was prescribed a renal diet due to dialysis treatments, did not receive the correct foods as per her dietary requirements. The cook, responsible for meal preparation, served the same meal to all residents, disregarding the specific menu items for therapeutic diets. The cook admitted to overlooking the therapeutic diet spreadsheets and attributed this oversight to inadequate training and support during his initial days at the facility. Further investigation revealed that the Diet Order Tally Record, which should guide the preparation of meals for different diet types, had not been updated since mid-December, despite the Food and Nutrition Services Director's claim of daily updates. Additionally, some residents had signed risk/benefit forms to decline therapeutic diets, but others, including those affected by the oversight, had not. The facility's policy on therapeutic diets mandates that these diets be prescribed by a physician and regularly reviewed, but the failure to follow these procedures led to the deficiency.
Privacy Violation Due to Unauthorized Photo
Penalty
Summary
A certified nursing assistant (CNA) took a photo of a resident's head injury without permission, violating the resident's right to privacy. The incident occurred after the resident had fallen and sustained a head injury, which was assessed by a registered nurse (RN). The CNA, who was concerned that the resident should have been sent to the hospital, took the photo but did not share it with anyone. The CNA was an agency staff member and had previously signed the Health Insurance Portability and Accountability Act (HIPAA) corporate training. The resident involved in the incident was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 0, and had been admitted to hospice for end-of-life care. The resident's medical conditions included moderate protein-calorie malnutrition, anxiety disorder, major depressive disorder, and a urinary tract infection. The resident required assistance from two staff members for transfers between surfaces. The CNA's action of taking a photo without permission led to a privacy violation, as there were no identifying marks in the photo, and the photo was not shared with others.
Failure to Monitor Neurological Changes Post-Fall
Penalty
Summary
The provider failed to adequately monitor five residents for neurological changes after they experienced falls. Resident 2, who was severely cognitively impaired and on hospice care, had an unwitnessed fall and was found with a lump and abrasions on her head and lip. Although a registered nurse completed an initial assessment, the required neurological evaluations were not conducted at the designated times. Similarly, Resident 3, who was cognitively intact and had a history of cardiac issues, fell in the hallway, and while an initial assessment was performed, the subsequent neurological evaluations were not completed as required. Residents 4, 5, and 6 also did not receive the necessary neurological evaluations following their falls. The Director of Nursing (DON) acknowledged that RN I, who was responsible for the initial assessments, had not completed the neurological evaluations as per the facility's policy. The DON had previously educated the staff on the importance of these evaluations but had not provided any new training since October. The facility's policy mandates neurological evaluations for 72 hours following an unwitnessed fall or head injury, with specific intervals for assessments. The failure to adhere to this policy resulted in a deficiency in monitoring the residents' neurological status post-fall.
Failure to Conduct Hot Liquid Assessment and Monitor Beverage Temperatures
Penalty
Summary
The facility failed to ensure resident safety by not completing a hot liquid assessment at the time of admission for a resident who spilled coffee on herself. The resident, who was moderately to severely cognitively impaired due to Alzheimer's/Dementia, did not sustain any injury from the incident. However, the lack of a hot liquid assessment at admission was a significant oversight, as the resident's baseline care plan indicated impaired cognitive function. The incident revealed that the facility did not have a consistent process for assessing the risk of hot liquid spills for new admissions. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed that hot liquid assessments were only conducted if a problem arose, such as a spill. Additionally, the facility's temperature log sheets for coffee and hot water were inconsistent, with some logs missing or showing conflicting temperatures, indicating a lack of proper monitoring and documentation. Observations in the dining hall showed that hot beverages were being served without verified temperature checks, as there were no temperature log sheets near the coffee makers. The facility's policy required that hot beverage temperatures not exceed 150 degrees Fahrenheit at resident contact, but this was not consistently enforced. The failure to adhere to these procedures and policies contributed to the deficiency in ensuring a safe environment for residents.
Failure to Administer Physician-Ordered Antibiotic Treatment
Penalty
Summary
The provider failed to administer physician-ordered antibiotic treatment and monitoring for a resident who had an infection and was readmitted to the hospital. The resident, who had moderate cognitive impairment, was readmitted to the facility with a diagnosis of clostridium difficile and had an order for Vancomycin HCI Oral Suspension. However, upon re-admission, the admitting team incorrectly entered the antibiotic order into the electronic medical record (EMR) system as unsupervised medication administration, indicating the resident was to self-administer the medication unsupervised. As a result of this error, the resident missed 16 scheduled doses of Vancomycin, which were incorrectly marked as unsupervised self-administration on the medication administration record (MAR). Despite the missed doses, nurses charted that the resident did not have any adverse side effects from the medication on several occasions. The resident was eventually readmitted to the hospital for hyponatremia and hyperglycemia, along with loose stools, after the error was discovered and corrected. Interviews with staff revealed a lack of awareness and communication regarding the incorrect medication order. The admission team, responsible for transcribing and double-checking medication orders, failed to identify the error. Additionally, the certified medication aides (CMAs) and nurses did not question the green box on the MAR, which indicated the medication had already been given. The director of nursing services acknowledged the communication gap and confirmed that the resident had not received the prescribed doses of Vancomycin.
Resident Fall Due to Incorrect Sling Size
Penalty
Summary
A resident experienced a fall from a full mechanical lift, which resulted in hospitalization for a right hip fracture. The incident occurred when the resident was being transferred using a sling that was too large, causing her to become unbalanced and slide out of the sling onto the floor. At the time of the fall, the resident was cognitively intact and had multiple diagnoses, including cardiomyopathy and atrial fibrillation. The resident's care plan was not followed correctly, as the incorrect sling size was used during the transfer. Interviews with staff revealed that the sling used was not appropriately sized for the resident, and the shoulder straps were longer than needed. The CNA involved in the transfer admitted that the sling used was the one available with the lift, regardless of size. The RN on duty confirmed that the sling was placed incorrectly, contributing to the fall. The facility's fall policy required specific actions and notifications following a fall, but the incorrect use of equipment led to the incident.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The report identifies a deficiency in the facility's ability to provide adequate staffing to meet the needs of residents, particularly in responding promptly to call lights. Observations and interviews revealed that residents experienced significant delays in receiving assistance, with some waiting over 30 minutes for staff to respond to call lights. This issue was prevalent across multiple residents, including those who required mechanical lifts for transfers, which further complicated timely assistance due to the limited availability of lifts and staff. Interviews with residents and their family members highlighted the impact of these delays, with reports of residents waiting excessively long times for assistance with transfers and toileting. Some residents expressed feelings of frustration and embarrassment due to incontinence incidents resulting from the delays. The call light audit reports corroborated these accounts, showing numerous instances of extended wait times, some exceeding 45 minutes. Staff interviews revealed that the facility was often understaffed, with CNAs responsible for a large number of residents, making it challenging to provide timely care. The facility lacked specific policies for call light response times and lift usage, contributing to the inconsistency in care delivery. Despite conducting call light audits, the facility's administration did not recognize the extent of the problem, and there was no established protocol for addressing the delays in call light responses.
Failure to Administer Medications as Ordered
Penalty
Summary
The provider failed to correctly administer medications as ordered for a resident who required hospitalization. The resident was admitted to the facility with diagnoses including hypopotassemia, anemia, acute kidney injury, chronic kidney disease stage III, hypertension, and malignant neoplasm of the bladder. Upon admission, the resident had a potassium level of 2.8, which is below the normal range. The hospital discharge orders included medications such as folic acid, potassium chloride, sodium bicarbonate, and urea-lactic acid cream. However, the resident did not receive the prescribed doses of folic acid and potassium chloride on multiple occasions from the time of admission until the resident was hospitalized again for low potassium levels and other complications. The facility's medication administration record (MAR) revealed that the resident missed doses of folic acid and potassium chloride. Progress notes indicated that the pharmacy had reviewed the admitting orders, but the medications were not administered as required. The resident's potassium level remained critically low, leading to a transfer to the emergency department and subsequent admission to the ICU for intravenous potassium administration. Interviews with the facility staff, including the executive director, registered nurses, and licensed practical nurses, confirmed that the medication orders were not properly entered, double-checked, or confirmed in the electronic medical record (EMR) system, leading to the missed doses. The director of nursing and the minimum data set coordinator confirmed that the resident had not received the medications as ordered. They acknowledged that the EMR integration and the pending confirmation notice for new orders contributed to the medication errors. A medication error form was completed, and the resident's primary care provider was updated on the situation. The facility had an emergency medication supply (E-kit) that could have been used, but it was not utilized in this case. The staff interviews and record reviews highlighted the deficiencies in the medication administration process, leading to the resident's hospitalization.
Failure to Assess Smoking Safety for Residents
Penalty
Summary
The provider failed to ensure that two residents who smoked were assessed for safety. Resident 1, who was at risk for elopement and wore a Wanderguard, was allowed to go outside independently by a receptionist who misinterpreted instructions from the DON. Resident 1 had a history of asking for cigarettes and became upset when staff refused to take him outside to smoke. A smoking safety assessment for Resident 1 was only completed after he left the property without staff knowledge to smoke a cigarette. Resident 2, who smoked cigarettes, was not aware of any designated smoking area and had not been assessed for smoking safety. She relied on a friend to take her outside to smoke and did not receive assistance from staff. Despite being aware that both residents smoked, the DON admitted that smoking safety assessments were not routinely completed for residents who smoked. The facility's policy required smoking safety evaluations on admission and with changes in condition, but these were not followed. The facility also had a Smoke-Free Center Policy Acknowledgement form signed by both residents on admission, but this policy was not effectively enforced or communicated to staff and residents. The provider's updated Resident Smoking Safety policy outlined specific procedures for smoking safety evaluations and designated smoking areas, but these were not adhered to, leading to the deficiency.
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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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