Flandreau Santee Sioux Tribe Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Flandreau, South Dakota.
- Location
- 909 Jones Dr, Flandreau, South Dakota 57028
- CMS Provider Number
- 43A139
- Inspections on file
- 14
- Latest survey
- September 30, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Flandreau Santee Sioux Tribe Care Center during CMS and state inspections, most recent first.
A CNA transported two residents in wheelchairs at the same time, leading to one resident's wheelchair catching on a window frame and causing a fall with a hip fracture. The resident, who had rheumatoid arthritis and contractures, was not using foot pedals as per her care plan. Staff interviews revealed inconsistent understanding of safe transport protocols and a lack of recent education on fall prevention. The facility's investigation was limited and did not include comprehensive staff education or clear documentation of safety expectations.
Staff did not consistently document food temperatures for 40 out of 192 meals, resulting in a lack of evidence that meals were heated to safe temperatures before serving. The dietary manager and interim administrator confirmed that kitchen staff were responsible for this documentation, and that missing records meant there was no proof food safety standards were met.
A resident with severe cognitive impairment, vascular dementia, and a known history of wandering eloped from the facility despite having a wander guard device and care plan interventions in place. After the front door wander guard alarm sounded, a CNA checked the immediate area but did not locate the resident, who was later found by an RN walking off the premises. The incident demonstrated a failure to provide adequate supervision and ensure the safety of a resident at high risk for elopement.
Surveyors found expired medications, including Tylenol, Carbidopa/Levodopa, Diphenhydramine, and Gabapentin, on two medication carts. Both an RN and a CMA confirmed the expired drugs were present and should have been removed by night nursing staff. The DON stated there was no checklist or policy for checking and removing expired medications, leading to the deficiency.
The facility failed to adequately supervise residents who smoked or vaped, resulting in a burn injury and inconsistent safety assessments. Additionally, a resident with a history of elopement was allowed to walk unsupervised and left the facility grounds without staff knowledge, highlighting deficiencies in the implementation of safety policies.
A resident with paraplegia suffered a burn on her abdomen from a hot microwave meal prepared by an RN. The RN followed package instructions and informed the resident about the meal's temperature, but later found blisters on the resident's abdomen. The RN documented the injury and applied a dressing but did not complete a risk management report or notify the primary care provider immediately.
Two residents' care plans were found to be incomplete and not individualized, failing to reflect their current needs for ADL and pressure ulcer prevention. Despite using pressure-relieving equipment, their care plans lacked specific interventions. Staff interviews revealed issues with updating care plans due to unfamiliarity with the EMR system and recent staff vacancies.
Failure to Prevent Accident During Wheelchair Transport Results in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to safely transport a resident in a wheelchair, resulting in the resident falling and sustaining a fractured hip. The CNA was pushing two residents simultaneously in their wheelchairs when one wheelchair caught on a window frame, causing the resident to fall forward onto her right hip. The resident, who had rheumatoid arthritis and contractures in her hands and knees, experienced significant pain and required emergency surgery for the hip fracture. The incident was witnessed by staff and captured on security video, confirming that the CNA was pushing two residents at once, which was not the proper procedure. Interviews with staff and residents revealed that there was inconsistency in staff understanding and adherence to safe wheelchair transport protocols. Several staff members, including CNAs and LPNs, reported that they had not received recent education or follow-up training regarding safe resident transportation or fall prevention policies. Some staff were unaware of the facility's policies or where to find them, and there was confusion among newer staff about whether transporting two residents at once was acceptable. The facility's investigation documentation did not include evidence of comprehensive staff education or clear communication of safety expectations following the incident. The resident involved in the fall had a care plan indicating dependence on staff for wheelchair locomotion and a need for reminders to use foot pedals, which she often refused due to her contractures. At the time of the incident, the resident was not using foot pedals, and the facility had noted a general lack of available wheelchair foot pedals. The facility's falls policy did not include provisions for staff education to prevent falls, and the investigation into the incident was limited, with only the CNA and the resident directly involved being interviewed. No disciplinary action or formal follow-up education was documented for the staff involved.
Failure to Document Food Temperatures for Resident Meals
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Summary
The facility failed to follow food safety standards by not consistently monitoring and documenting food temperatures for meals served to residents. Specifically, for 40 out of 192 meals served between 5/1/25 and 8/3/25, there was no documentation to confirm that food temperatures were checked prior to serving. Observations in the kitchen revealed that while temperature log books for breakfast, dinner, and supper were present, staff acknowledged that some meal temperatures were not recorded. The cook confirmed that not all food temperatures were documented, and the certified dietary manager also acknowledged the lack of documentation for certain meals. Interviews with the certified dietary manager and the interim administrator confirmed that the responsibility for checking and documenting food temperatures rested with the kitchen staff, and that missing documentation meant there was no proof that food was heated to the required safe temperatures before being served. Review of the facility's food preparation and service policy outlined specific temperature requirements for various foods, but the lack of consistent documentation indicated that these standards were not always met.
Failure to Prevent Elopement of High-Risk Resident
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Summary
A deficiency occurred when staff failed to ensure the safety and adequate supervision of a resident identified as being at high risk for elopement. The resident, who had severe cognitive impairment, vascular dementia, a history of wandering, and was ambulatory, was last seen on the unit by staff before the front door wander guard alarm was triggered. After the alarm sounded, a CNA responded, checked the immediate area outside the front door and parking lot, but did not see anyone and returned to the facility, shutting off the alarm. Staff were then notified and a facility-wide search was initiated. The resident was eventually found by an RN walking approximately two-tenths of a mile from the facility, having left without staff knowledge. The resident's medical record indicated a history of wandering and a high risk for elopement, with care plan interventions in place, including the use of a wander guard device and regular checks to ensure its functionality. Despite these interventions, the resident was able to exit the facility undetected and was not immediately located after the alarm was triggered. The incident was reported to the DON, administrator, and tribal police, and the resident was returned safely to the facility. The failure to provide adequate supervision and respond effectively to the elopement risk resulted in the resident leaving the facility unsupervised.
Expired Medications Found on Medication Carts Due to Lack of Policy and Oversight
Penalty
Summary
Surveyors observed that two medication carts contained expired medications, including Tylenol 325 mg, Carbidopa/Levodopa 25/100 mg, Diphenhydramine 25 mg, and Gabapentin 600 mg. These expired medications were available for administration to residents. Both a registered nurse and a certified medication aide confirmed the presence of expired medications and acknowledged that night nursing staff were responsible for checking and removing expired medications from the carts. Further interviews with the director of nursing revealed that there was no night shift checklist that included the task of checking for expired medications, and the facility did not have a policy regarding expired medications. The lack of a formal process or policy contributed to the failure to remove expired medications from the medication carts.
Deficiencies in Resident Supervision and Safety
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Summary
The report identifies several deficiencies related to the supervision and safety of residents who smoke or vape at the facility. Specifically, the facility failed to effectively implement and follow its smoking policy for multiple residents. One resident suffered a cigarette burn on her abdomen due to inadequate supervision and refusal to wear a smoking apron, which was a required safety measure. The facility's smoking policy required residents to be supervised while smoking, but observations revealed that supervision was sometimes conducted from inside the building, which may not have been adequate. Additionally, the facility did not have a vaping policy, and the smoking safety screens were not consistently completed or updated for residents who smoked or vaped. Another significant deficiency involved a resident with a known history of elopement who was allowed to walk outside the facility unsupervised. This resident, who had moderate cognitive impairment, left the facility grounds without staff knowledge and was missing for over an hour. The facility's policy required residents at risk of elopement to be adequately supervised, but the resident was permitted to walk alone as a non-pharmacological intervention for his behaviors. The facility's response to the resident's absence was delayed, and the resident was eventually found at a nearby apartment complex. The facility's policies on smoking and elopement were not adequately followed or enforced, leading to safety risks for the residents involved. The lack of consistent smoking safety assessments and the failure to update care plans to reflect residents' current needs contributed to these deficiencies. The facility's elopement policy required systematic monitoring and management of residents at risk, but the implementation of these measures was insufficient, as evidenced by the resident's unsupervised departure from the facility.
Resident Suffers Burn from Hot Microwave Meal
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Summary
A resident with a diagnosis of paraplegia suffered a skin burn wound on her abdomen from hot food prepared by a registered nurse (RN) in a microwave. The incident occurred when the resident requested the RN to make a freezer meal in the microwave. The RN cooked the meal according to package instructions and informed the resident that the item was hot and advised her to let it cool before eating. Later, when the RN assisted the resident into bed, she noticed a red circle mark with four blisters on the resident's abdomen. The RN documented the skin condition in the resident's chart and applied a Mepilex dressing to the blistered area. However, the RN did not complete a risk management report or immediately notify the primary care provider to obtain orders for the burn. The incident was reported to the morning nurse, but the facility initially did not consider it a reportable incident due to the education provided to the resident about the hot meal.
Incomplete and Non-Individualized Care Plans for Residents
Penalty
Summary
The provider failed to ensure that care plans reflected the current individualized activities of daily living (ADL) and pressure ulcer prevention and treatment needs for two residents. Resident 2, who has paraplegia and a pressure ulcer, was observed using an air mattress and positioning cushions for pressure relief. Despite these observations and her reliance on staff for most care needs, her comprehensive care plan did not include interventions for her pressure ulcer or prevention measures. Similarly, Resident 1, diagnosed with alcohol-induced persisting dementia and muscle weakness, was observed using an air mattress and a pressure-relieving cushion. However, his care plan lacked complete and individualized focus areas, goals, and interventions, including those for pressure ulcer prevention. Interviews with staff revealed systemic issues in care plan management. A certified nursing assistant (CNA) and a registered nurse (RN) described using care sheets and electronic medical records (EMR) for documenting resident care, but these were not consistently updated to reflect current needs. The Minimum Data Set (MDS) coordinator acknowledged that the care plans for both residents were incomplete and not individualized, attributing this to her unfamiliarity with the new Point Click Care (PCC) EMR system. The administrator confirmed that care plans were not updated as expected due to recent staff vacancies, which affected the weekly review process. The facility's policy on Pressure Injury Risk Assessment emphasized the need for resident-centered care plans based on risk factors, skin condition, and clinical status. However, the care plans for the two residents did not align with these standards, as they were not modified to reflect changes in the residents' conditions or deemed inadequate interventions. This lack of adherence to policy contributed to the deficiencies observed in the care plans.
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
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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
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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
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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
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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
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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
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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
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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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