Good Samaritan Society Luther Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux Falls, South Dakota.
- Location
- 1500 W 38th St, Sioux Falls, South Dakota 57105
- CMS Provider Number
- 435044
- Inspections on file
- 24
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Good Samaritan Society Luther Manor during CMS and state inspections, most recent first.
A resident with quadriplegia who relied on baclofen to manage muscle stiffness and spasms experienced a significant medication error when an RN misread a pharmacy communication about a future stop date and discontinued baclofen without a physician’s order. The resident subsequently developed altered mental status, facial redness, and behavioral changes, leading to transfer to the ED and hospital admission, where acute encephalopathy likely due to baclofen withdrawal was diagnosed. The medical director, DON, and administrator all stated that a physician’s order and clarification on discontinuation of such a medication would have been expected before stopping it.
A resident with mild cognitive impairment and a known elopement risk, who had refused a wander guard and was to be checked every three hours, was last documented as seen at midday and later left the building by independently using the front door keypad code, remaining unsupervised outside until returning the next day. The front door keypad code had been unchanged for years, was posted in reverse on a laminated sign above the keypad, and was known to some residents, allowing them to open the door. At the same time, after an EMR system update, staff stopped routinely completing the required elopement risk assessment on all new admissions, and several newly admitted residents had no documented elopement screening despite facility policy requiring universal admission screening.
The facility failed to report a fall incident and multiple verbal abuse allegations to SD DOH within required time frames. A resident who required two-person assistance with a sit-to-stand mechanical lift was transferred by one CNA, slipped from the sling to the floor, and was later reported to SD DOH beyond the 24-hour requirement. In a separate situation triggered by a staff member’s quality-of-care concerns, a resident reported being told to shut up and sit up or help would be withheld, and two other residents described rude and inappropriate comments by a CNA; these abuse allegations were not reported within the mandated 2-hour window. Another resident’s frequent call light use for leg pain and repositioning led to findings that a CNA used profanity when speaking with staff about a resident. The DON acknowledged that these events were not reported in accordance with the facility’s abuse/neglect policy and state reporting timelines.
A resident with a history of falls, dementia, and muscle weakness sustained an injury after staff failed to follow the care plan requiring a silent TABs alarm in both the bed and recliner. The alarm was left in the recliner instead of being placed on the bed, and staff interviews and observations confirmed that only one alarm was being used and transferred between locations, contrary to the care plan. Additional required interventions, such as signage, were also not in place, and staff were not consistently aware of or following the prescribed fall prevention measures.
A resident with a history of stroke and dysphagia received water through a straw, despite a care plan specifying no straws and special hydration needs. The restriction was documented in the care plan but was not transferred to the Kardex, leaving front-line staff unaware of the requirement. Staff interviews confirmed reliance on the Kardex for such information, resulting in the resident not receiving care as ordered.
A resident with a history of UTIs was found with two Buprenorphine patches on their skin, leading to altered mental status. The facility failed to remove the previous patch before applying a new one, due to a delay in medication delivery and lack of adherence to the patch management process. Staff interviews revealed confusion about medication availability and inconsistent verification of patch removal.
A resident with a history of stroke was injured during a transfer with a sit-to-stand mechanical lift due to inadequate staff assistance and supervision. Despite the care plan requiring two staff members for transfers, only one was often present, leading to a fall and head injury. The resident expressed fear and discomfort with the lift, but it continued to be used without proper reevaluation. The facility failed to ensure proper documentation and communication of transfer needs, contributing to the deficiency.
The facility failed to properly store, label, and maintain cleanliness of food items in the kitchen and kitchenette areas. Observations revealed unlabeled and undated food, spoiled items, and unsanitary conditions. Cleaning logs were incomplete, and the director of dining services acknowledged the issues.
A resident's care plan was not updated after her catheter was removed, despite confirmation from the resident and staff that she no longer had it. The care plan still required Enhanced Barrier Precautions for a Foley catheter, which had been discontinued. Staff interviews revealed a lack of communication and adherence to the facility's policy on care plan updates.
Significant Medication Error from Unauthorized Discontinuation of Baclofen
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an RN discontinued a critical medication without a physician’s order. The resident, who had quadriplegia and was receiving baclofen as a primary medication to manage involuntary muscle stiffness and spasms, experienced an abrupt discontinuation of this drug. RN C received a Consultant Pharmacist Communication to Physician asking the physician to clarify whether baclofen and duonebs, which had a stop date of 2/1/2027 on the MAR, should be discontinued at that time or continued. RN C misread the year on the stop date, believed the medications should have been discontinued on 2/1/2026, and independently stopped the resident’s baclofen on 3/18/26 without waiting for the physician’s verification or obtaining an order. Following the discontinuation, the resident developed a change in mental status, facial redness, and behavior that was described as not acting himself on 3/20/26. He was sent to the ED for evaluation at approximately 9:00 p.m. and was admitted to the hospital later that evening. He was diagnosed with acute encephalopathy, likely due to baclofen withdrawal after the abrupt discontinuation. Interviews confirmed that the medical director, who was the resident’s primary physician, would have expected to be contacted before any medication was discontinued and expected nursing staff to obtain clarification on how a medication like baclofen should be discontinued to ensure it was done safely. The DON and administrator both confirmed that a physician’s order was expected before discontinuing a resident’s medication, and the DON identified this event as a significant medication error.
Failure to Secure Exit Door and Consistently Assess Residents for Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents, specifically related to elopement risk and door security. One resident, who was admitted with an identified elopement risk and had a BIMS score of 11 indicating mild cognitive impairment, refused a wander guard, so staff were to perform and document three-hour rounding to verify his whereabouts. On the day of the incident, his last documented three-hour check occurred at 12:00 p.m., and he was later reported missing at 8:00 p.m. after dietary staff noted his absence from the evening meal. A review of camera footage showed that he had tested and successfully used the front door keypad code earlier in the day and exited the building at 5:04 p.m., remaining outside the facility unsupervised for about 18.5 hours until he returned in a private vehicle the following day. The report further documents that the front door keypad code had been in place for several years and was not changed immediately after the elopement. The keypad was located near the front door with a laminated paper above it displaying the code written backwards, which could be read and used by anyone with intact cognition. Observations showed a visitor reading the laminated sign and entering the code to exit. Staff interviews confirmed that some residents, including the eloping resident, knew and used the door code to go outside. The resident whose room was closest to the front door stated he had watched people use the keypad, learned the code, tested it earlier in the day, and then chose a time when staff were busy to leave the building. The code remained unchanged from the time of his elopement until several days later. In addition, the facility did not consistently assess newly admitted residents for elopement risk as required by its elopement policy. The policy stated that all residents would be assessed for elopement risk during the pre-admission and/or admission process using a user-defined assessment (UDA) in the electronic medical record system, with results used to individualize care plans. After a software update to the Point Click Care (PCC) system in December 2025, the elopement assessment no longer opened automatically, and the nurse responsible for admission assessments reported that she only completed elopement assessments if residents expressed a desire to leave or had certain clinical risk factors. The admission checklist was also no longer used. Record review showed that three newly admitted residents during the review period had no documented admission elopement screening assessments in their EMRs, and leadership acknowledged that not all residents were being screened on admission as required by policy.
Failure to Timely Report Fall Incident and Verbal Abuse Allegations to SD DOH
Penalty
Summary
The deficiency involves the facility’s failure to report certain incidents and allegations to the South Dakota Department of Health (SD DOH) within required time frames. For one resident who required a sit-to-stand mechanical lift with two-person assistance per the care plan, a CNA performed the transfer alone. During the transfer, the resident slipped from the sling, slid to the floor onto his bottom, and rolled onto his right side. An LPN immediately assessed the resident and found no injury, but the incident, which occurred on 11/28/25 at 11:30 a.m., was not reported to the SD DOH until 12/1/25, exceeding the 24-hour reporting requirement for such events. The facility also failed to timely report allegations of verbal abuse involving another resident. After a CNA left her shift early and raised quality of care concerns, the administrator and DON interviewed residents and staff. One resident reported that a CNA told her not to sing and to “shut up” and “sit up or I am not going to help you.” Two additional residents reported that the same CNA made rude and inappropriate comments, including “You would not have these issues if you went out to the dining room” and “Don’t be cocky.” Although the CNA denied making rude or inappropriate comments, these allegations of verbal abuse were not reported to the SD DOH until six days after the DON was notified, well beyond the required two-hour reporting window for abuse allegations. A third deficiency involved another resident and additional allegations of verbal abuse. Following the same initial staff report of quality of care concerns, the facility investigated and learned that a CNA reported the resident had used the call light several times during the night for leg pain and repositioning needs. The CNA stated she did not use profanity toward residents while providing care but acknowledged using profanity at times when talking with other staff members about a resident, as an expression of how she felt. The DON later confirmed that reports of resident abuse and neglect were required to be reported to the SD DOH within two hours, and all other reportable events within 24 hours, and acknowledged that the verbal abuse allegations related to these residents, as well as the earlier fall incident, were not reported within the required time frames. The facility’s own abuse and neglect policy required immediate reporting, but not later than two hours, for allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property, or serious bodily injury, and within 24 hours for other allegations without serious bodily injury.
Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions as described in the care plan for a resident with a history of repeated falls, muscle weakness, dementia, and use of anticoagulants. The resident was found on the floor next to his bed with a laceration near his right eye, requiring emergency department treatment and sutures. The facility's investigation revealed that the silent TABs alarm, intended to alert staff when the resident attempted to stand, was left in the resident's recliner instead of being placed on the bed, as required by the care plan. The certified nursing assistant who assisted the resident to bed forgot to move the alarm, resulting in the alarm not being in place at the time of the fall. Further review of the resident's medical record and care plan showed that the resident was care planned to have a silent TABs alarm in both his bed and recliner at all times, with instructions to ensure the alarm was used, plugged in, and functioning when the resident was in either location. However, multiple progress notes documented that the alarm was not consistently placed under the resident at bedtime and was often found in the recliner while the resident was in bed. Staff interviews confirmed that only one alarm was being used and transferred between the bed and chair, rather than having two alarms as specified. Some staff were unaware of the care plan requirements, and others reported that attempts to use two alarms resulted in malfunctions, leading to the removal of the second alarm without alternative interventions being consistently implemented. Observations confirmed that the resident's room did not have two alarms as required, and the STOP, Wait for assistance sign, which was supposed to be in place as an additional intervention, was not visible. Interviews with nursing and administrative staff revealed a lack of awareness regarding the specific fall prevention interventions required for the resident, and documentation of these interventions was inconsistent. The facility's fall prevention policy emphasized the need to identify risk factors and implement interventions before a fall occurs, but these procedures were not followed in this case.
Failure to Communicate Hydration Restrictions Leads to Care Plan Deviation
Penalty
Summary
Staff failed to follow the care plan regarding hydration needs for a resident with a history of stroke, hemiplegia, and dysphagia. The resident was observed receiving medications with pudding and water through a straw, despite care plan instructions specifying mildly thickened liquids with meals, thin liquids in the room only after oral care, and no use of straws as per speech therapy recommendations. The certified medication aide administering the medication was unfamiliar with the resident's specific needs, and the water mug in the resident's room contained a straw, contrary to the care plan. Interviews with dietary and nursing staff revealed that the restriction on straw use was documented in the care plan but was not transferred to the Kardex, the tool used by front-line caregivers to access residents' care needs. Both the CNA and RN confirmed reliance on the Kardex for such information, and the DON was unaware of the no-straw requirement. The facility's policy required care plans to reflect current care needs and ensure appropriate care and services, but the failure to update the Kardex led to staff not being informed of the resident's hydration restrictions.
Failure to Remove Previous Buprenorphine Patch Leads to Double Application
Penalty
Summary
The deficiency involved a failure to properly manage the administration of Buprenorphine transdermal patches for a resident, leading to the application of two patches simultaneously. The resident, who had a history of neurogenic bladder and urinary tract infections, was found with two Buprenorphine patches on his skin when evaluated at a hospital for altered mental status. The resident had an order to apply one patch every seven days, but due to a delay in delivery, a second patch was applied without removing the first one. The incident occurred because the nurse who applied the second patch was unaware that the previous patch had not been removed. The facility's process for managing transdermal patches was not followed correctly, as evidenced by the lack of signatures on the narcotic patch placement form and the failure to verify the removal of the previous patch. Interviews with staff revealed that there was confusion about the availability and delivery of the medication, and the process for checking and removing old patches was not consistently followed. The director of nursing service acknowledged the incident and reported it to the South Dakota Department of Health. Despite the resident's history of UTIs, the hospital suspected that the altered mental status was due to the double application of Buprenorphine patches. The facility had not provided new education to all staff regarding the process for applying and removing transdermal patches, and there was no updated policy since the incident, indicating a gap in ensuring compliance with medication administration procedures.
Deficiency in Resident Transfer Safety and Supervision
Penalty
Summary
The report identifies a deficiency in the safety and supervision of a resident who required assistance during transfers with a sit-to-stand mechanical lift. The resident, who had a history of stroke resulting in weakness in the left leg and arm, was involved in an incident where he was dropped in the shower room, leading to a head injury and a hospital visit. Despite the care plan indicating the need for two staff members to assist with the lift, observations revealed that only one staff member was often present during transfers, which compromised the resident's safety. Interviews with staff members, including CNAs and LPNs, highlighted a lack of awareness and adherence to the care plan. One CNA admitted to transferring the resident alone, believing he required only one assist, while another staff member was unaware of the resident's discomfort and fear of using the lift. The resident expressed concerns about the lift's safety, indicating that it caused discomfort and fear during transfers. Despite these concerns, the lift continued to be used without proper reevaluation or adjustment to the resident's needs. The facility's failure to ensure proper documentation and communication of the resident's transfer needs contributed to the deficiency. The Kardex, which contained updated care instructions, was not consistently checked by staff, leading to improper transfer methods. Additionally, the facility's fall prevention policy was not effectively implemented, as evidenced by the lack of timely updates to the care plan and inadequate staff training on the use of mechanical lifts. This oversight resulted in the resident's fall and subsequent injuries, highlighting a significant lapse in the facility's duty to provide a safe environment for its residents.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The provider failed to ensure proper storage, labeling, and cleanliness of food items in the kitchen and kitchenette areas. Observations revealed multiple instances of unlabeled and undated food items, including cookies, butter, peanut butter, and various items in the walk-in refrigerator and freezer. Additionally, spoiled food items such as celery and salad were found, and some items were past their discard dates. The kitchen environment was unsanitary, with hardened substances on a metal cart, crumbs and substances on equipment like the Magic Bullet, and a lack of soap in the hand-washing sink. The serving area outside the kitchen also exhibited deficiencies, with food crumbs and debris between equipment, and unlabeled and undated food items such as cookies and blueberries. The refrigerator in this area contained expired and spoiled items, including thickened water and a salad labeled for a resident. The kitchenette in the 500-wing had similar issues, with unlabeled and undated food items, and expired thickened juices. The review of cleaning logs showed incomplete cleaning tasks, with many tasks left uncompleted over several weeks. The director of dining services acknowledged the issues, including the lack of awareness about the empty soap dispenser and the incomplete cleaning logs. The provider's policies on date marking and cleaning schedules were not adhered to, contributing to the deficiencies observed.
Failure to Update Care Plan After Catheter Removal
Penalty
Summary
The provider failed to update the care plan for a resident after the removal of her catheter. The resident, who was moderately cognitively impaired, confirmed during an observation and interview that she no longer had a catheter. However, her care plan still indicated the need for Enhanced Barrier Precautions due to an indwelling Foley catheter, which had been initiated months earlier. The resident's electronic medical record showed that the catheter was discontinued, and subsequent assessments confirmed its absence, yet the care plan was not updated to reflect this change. Interviews with facility staff, including a registered nurse and a certified nurse assistant, revealed that the care plan had not been revised to remove the catheter information. The RN responsible for updating care plans acknowledged that the care plan should have been updated and indicated that the nurse manager should have communicated the change. The facility's policy emphasizes the importance of care plans in coordinating services based on individual needs, but this was not adhered to in this instance.
Latest citations in South Dakota
Failure to Follow EBP and Hand Hygiene Practices: Staff did not wear gowns or gloves, did not perform hand hygiene, and did not clean an EZ stand lift after providing high-contact care to a resident on EBP with a Foley catheter. Staff also provided toileting care to a resident with open stage II pressure ulcers without gowns, and a housekeeper handled resident-room surfaces and items with unclean hands while cleaning rooms. Facility policy required gown and glove use for EBP, cleaning reusable equipment between residents, and hand hygiene after resident contact and glove removal.
A resident with severe cognitive impairment, TBI, and dementia with behavioral disturbances used a one-piece jumpsuit identified as a restraint intervention to address genital exposure and related behaviors. The EMR showed consent and physician approval, but the quarterly MDS and care documentation did not show whether the garment remained needed, whether less restrictive alternatives had been tried, or whether restraint reduction or elimination had been considered. Staff interviews confirmed the resident had not worn the garment in a long time, and the DON stated there was no restraint-specific documentation form to track its use or reassess the need for it.
Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
Failure to assess, document, and report new pressure ulcers: A resident with a pelvic fracture and intact cognition developed stage II pressure ulcers on both inner buttocks and a new pressure ulcer on the heel. Staff interviews and record review showed the DON/wound nurse did not document the heel wound or notify the MD, did not notify the MD when the left buttock ulcer was identified, and wound monitoring was not completed daily as required by the facility's own process.
Staff failed to follow a resident’s care-planned transfer needs. The resident had severely impaired cognition, a moderate fall risk score, and required dependent assistance with transfers, including a Hoyer lift with 2 staff or a sit-to-stand lift. Two CNAs lifted her by the underarms and pivoted her instead of using the ordered transfer method, and one CNA stated she did not use a gait belt because the resident was too tiny. The DON acknowledged the transfers were improper and unsafe because staff did not follow the care plan or Kardex.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Staff failed to honor several residents’ stated preferences regarding where they undressed for bathing, affecting their dignity and privacy. One resident reported that a CNA repeatedly undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his expressed wish to undress in the shower room. Other residents described similar experiences, stating that the CNA did not ask their preferences and routinely undressed them in their rooms before covering them with a sheet or blanket and taking them to the tub or shower room. Staff interviews confirmed that residents, particularly those requiring a mechanical lift, were typically undressed in their rooms and then transported covered, and the DON stated that facility protocol was to follow resident preference, consistent with the written dignity and privacy policy.
A resident reported that a contracted travel CNA placed hands down his pants while he was in bed, which he described as groping and not part of his usual care routine. Two RNs received this allegation; one counseled the CNA but did not notify leadership and did not know the required reporting time frame, while the other, who knew the 2‑hour reporting requirement, also failed to promptly inform the DON or administrator, delaying notification to state authorities and omitting contact with law enforcement and the ombudsman. In a separate incident, a resident’s family member reported suspected financial abuse to the social services designee, who informed the administrator, but the concern was not reported to the state agency or investigated as an abuse allegation; instead, the family was only given contact information for outside agencies. These actions did not follow the facility’s abuse policy requiring immediate internal reporting, prompt investigation, and timely reporting of all abuse and misappropriation allegations to the state agency.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
Failure to Follow EBP, Equipment Cleaning, and Hand Hygiene Practices
Penalty
Summary
Infection prevention and control practices were not followed during care for a resident on enhanced barrier precautions (EBP) who had a Foley catheter. During a transfer from a wheelchair to a recliner using an EZ stand lift, two CNAs/RMAs did not wear gowns or gloves, did not perform hand hygiene after the transfer, and one CNA/RMA placed the lift outside the resident’s room without cleaning it. One of the CNAs/RMAs stated she was expected to wear a gown and gloves for the transfer and remove them afterward, and the other stated she should have worn a gown and gloves and cleaned the lift after use. A second resident had open stage II pressure ulcers to both buttocks and a new pressure ulcer on the right heel, but was not placed on EBP. During observed toileting assistance, an RN and a CNA wore gloves but did not wear gowns while providing care to the resident’s open buttock wounds. The CNA applied barrier cream to the pressure ulcers and the rest of the buttocks. The RN stated the resident did not need EBP because the wounds did not have drainage, and the ADON/IP stated the resident was not on EBP because the pressure ulcer was not chronic. Housekeeping staff also did not follow hand hygiene practices while cleaning resident rooms. A housekeeper removed a mop head with bare hands, touched door handles without washing hands, and used unclean hands while moving between rooms and handling resident items and bathroom surfaces. The housekeeper stated she was supposed to wash her hands after cleaning a bathroom, after mopping, and between rooms, and the director of food and nutrition/housekeeping and housekeeping supervisor confirmed staff were to wash hands before and after glove use, after bathroom cleaning, and before and after mopping. Facility policy stated EBP required gown and glove use for high-contact care such as transferring and toileting, reusable equipment was to be cleaned and disinfected between residents, and hand hygiene was the primary means to prevent the spread of healthcare-associated infections.
Lack of Documentation for Ongoing Use of One-Piece Garment Restraint
Penalty
Summary
The provider failed to document whether one resident who used a one-piece jumpsuit as a restraint intervention was a candidate for restraint reduction, a less restrictive restraint method, or restraint elimination. The resident had severe cognitive impairment, a history of traumatic brain injury, and dementia with behavioral disturbances. He was observed seated in his wheelchair at breakfast and later in his recliner, repeatedly moving his feet, rocking his trunk, and placing his hand in and out of the waistband of his sweatpants. His EMR showed that the jumpsuit had been identified as a restraint intervention and that the resident's spouse had signed informed consent for its use. The record showed the resident had ongoing behaviors involving fondling himself and exposing his genitals, and staff requested physician approval for a one-piece garment to protect his dignity and prevent exposure to others. The physician approved the request. The quarterly MDS indicated the resident used a trunk restraint on a less-than-daily basis, and the MDS nurse's note stated that when available the resident would wear the one-piece jumpsuit. However, that assessment did not include documentation supporting continued use or discontinued use of the garment, and there was no indication that other alternatives had been tried. The behavioral tracking record documented other targeted behaviors, but fondling and exposing his genitals were not identified as targeted behaviors on that assessment. During interviews, an LPN stated the jumpsuit's zipper was on the backside of the garment, restricting the resident's access to his genitals, and said he had not worn it in a long time because of physical and cognitive decline. A CNA also stated she had not seen him wear the garment. The MDS nurse found the jumpsuit hanging in the resident's closet and acknowledged she did not know whether staff had completed restraint-related documentation. The DON stated there was no restraint-specific form to document when the jumpsuit was worn, what precipitated its use, what less restrictive interventions were tried, or how long it was worn, and acknowledged that without such documentation the quarterly assessment could not fully determine whether the jumpsuit remained needed or could be discontinued. The facility's restraint policy required least restrictive use, ongoing reevaluation, and quarterly review for restraint reduction, less restrictive methods, or elimination.
Failure to Follow Ordered Urology Consultation
Penalty
Summary
The nursing facility failed to follow a physician-ordered urology consultation for a resident with urinary retention and a Foley catheter. The resident had been hospitalized for a left femur fracture, and hospital records showed the Foley catheter was removed and later reinserted after a failed trial without catheter. After discharge to the skilled nursing facility, the physician was faxed about discontinuing the Foley catheter and responded to start Alfuzosin for 4 days and then attempt a trial without the catheter. When that trial failed, the physician ordered the Foley restarted and follow-up with urology. Subsequent physician progress notes in February, March, and April documented referral to urology for further evaluation and care, and the resident’s catheter care plan addressed Foley care but did not include a plan for removing the catheter. During interviews, an LPN stated she knew the resident was expected to be seen by a urologist but it had not yet occurred and she was not sure why. The DON and ADON/IP stated the physician was expected to call the urologist to make the referral and that the urology office would then confirm the appointment time. The ADON/IP recalled discussing the urology consultation with the physician during January rounds, but confirmed she did not discuss the status of the consultation during February, March, or April rounds and had no other discussions with the physician about it. The DON acknowledged the failure to follow the January physician-ordered urology consultation was 100% on the facility.
Failure to assess, document, and report new pressure ulcers
Penalty
Summary
The provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers for one resident who had returned to the facility from the hospital with a pelvic fracture and weakness and had an intact BIMS score of 15. The resident had a stage II pressure ulcer to the right inner buttock identified on 4/6/26, and later a stage II pressure ulcer to the left inner buttock was identified on 4/27/26. The record showed wound assessments on the right inner buttock, but the report states the wound assessment documentation was not completed weekly as required, and the physician was not notified when the left inner buttock ulcer was identified. The resident was observed sitting in a wheelchair on a Roho pressure-relief cushion and stated she had an open sore on her bottom. Staff interviews confirmed she had pressure ulcers on both inner buttocks, and a CNA reported finding a new pressure ulcer on the resident's right heel that was boggy and dark red and purple in color. An LPN stated the resident had stage II pressure ulcers to both inner buttocks and that the new right heel pressure ulcer had been found the previous day. The DON/wound nurse later stated she was not aware of the right heel pressure ulcer and could not find documentation of it or documentation that the physician had been notified. The record review showed the resident's wound assessments were completed on several dates for the right inner buttock ulcer, with measurements and descriptions documented, and the care plan addressed pressure ulcers to both inner buttocks. However, the DON/wound nurse stated nurses did not monitor pressure ulcers daily and that weekly skin assessments were the routine process. The provider's policy required nurses to document and report pressure ulcers, and the change-in-condition policy required physician notification within 24 hours for a significant change of condition. The DON/wound nurse stated she did not notify the physician when the left inner buttock ulcer was identified and planned to wait until the physician rounded at the facility later.
Unsafe Transfers Not Followed for a Resident With Care-Planned Lift Needs
Penalty
Summary
The nursing home failed to ensure safe transfers for resident 11, who had severely impaired cognition, a moderate fall risk score, and care-planned transfer needs requiring dependent staff assistance. Her revised care plan stated that she usually required a Hoyer lift with staff assist x 2 for transfers when she was not placing her feet on the ground for a pivot transfer with a gait belt and staff assist x 1-2, or a sit-to-stand lift. The resident was observed in the dining room being lifted by CNA F and CNA/RMA E, who each placed an arm beneath her underarms, raised her to standing, pivoted her, and lowered her into her wheelchair. CNA F later transferred the resident from the wheelchair to a recliner in the same manner and stated the resident could not bear her full weight and that she did not use a gait belt because the resident was too tiny. A separate observation showed CNA/RMA G using a sit-to-stand lift to transfer resident 11 from her wheelchair to the toilet and referring to the Kardex to confirm that a mechanical lift was required. The DON/wound nurse stated therapy assessed residents' mobility and transfer needs, those recommendations were added to the care plan, and the care plan information was then transferred to the Kardex so staff would know how to care for the resident. The DON acknowledged that CNA/RMA E and CNA F improperly and unsafely transferred resident 11 by failing to follow the transfer recommendations in the care plan and Kardex.
Failure to Maintain Safe Bed Systems and Prevent Accidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bed environment free from entrapment hazards and to provide adequate supervision and accident prevention for multiple residents. Surveyors observed that several residents had loose side rails or grab bars and mattresses that were not secured or properly fitted, creating gaps between the rails, mattress, and bedframe. One resident’s bilateral side rails could move away from the bed one to two inches, and there was a five‑inch gap between the top of his mattress and the headboard. Another resident, who was legally blind and had previously fallen out of bed during a dream and sustained a brain bleed, had a left side rail that could move three inches away from the mattress; he reported telling a CNA and his daughter about the loose rail about a week earlier. A third resident used bilateral side rails for bed mobility; her right rail could move two to three inches away from the bed, the openings within the rails measured three and one‑half inches wide by 13 inches high, and there was a seven‑inch gap between the foot of her mattress and the footboard. Surveyors also found that the facility’s entrapment assessments and maintenance audits were incomplete or inaccurately documented. Review of the maintenance logbook for side rail inspections from January through April showed that only zone 1 (the opening within the side rail) was consistently assessed, while the other six FDA‑defined entrapment zones were often marked as not applicable, including zone 7 (the space between the mattress and headboard or footboard) even for residents without bed rails. In some months, all seven zones were documented as not applicable for numerous residents known to have side rails, and some residents with side rails were not included in the audits at all. The DON was unsure if there was a specific entrapment assessment policy and believed maintenance handled these assessments, while also acknowledging missing documentation for side rail assessments, consents, and physician orders, and that some side rails were installed without proper documentation. Additional deficiencies related to accident prevention and supervision were identified in several facility‑reported incidents. One resident with a history of stroke and left‑sided weakness fell from his bed while trying to remove his socks after a CNA left his bed at waist height; his care plan at that time did not specify a required bed height, and he was later diagnosed with a minor closed head injury and abrasions. Another resident, care planned to require two staff for transfers and use of a sit‑to‑stand lift, was transferred by a single contracted CNA using a sling that was too small and the wrong hook, causing back pain; the resident and his family reported that he was often transferred by only one staff member despite the care plan. A cognitively impaired resident at risk for elopement exited through a door whose alarm had been deactivated during daytime hours so visitors could enter and exit, walked outside in very cold weather, and re‑entered through another door after about 15 minutes. A further resident, on anticoagulant therapy, fell while transferring herself to the bathroom and hit her head; she had fallen 11 times in 30 days, and the provider failed to implement, review, and revise interventions to reduce her fall risk. These events collectively demonstrate failures to follow care plans, maintain environmental safety devices such as alarms and bed systems, and provide adequate supervision to prevent accidents. The surveyors determined that these failures, particularly the unsecured side rails and unassessed mattress gaps, created a risk for entrapment injury or harm and issued an Immediate Jeopardy finding under F689 related to accident hazards and supervision. Observations throughout the building confirmed multiple safety concerns with side rail installation, maintenance, and bed zone assessments, including loose rails and significant gaps between mattresses and headboards or footboards. Facility leadership and maintenance staff acknowledged that gaps between mattresses and bed ends and loose side rails posed a risk for entrapment and injury, and that entrapment zone measurements and assessments had not been consistently completed according to FDA guidance and facility policy.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Honor Resident Bathing and Undressing Preferences
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity, respect, and self-determination regarding bathing and undressing practices. One resident reported in a facility reported incident that on his bath days, a CNA undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his stated preference to undress in the shower room. During a later interview, this resident stated that the CNA continued this practice, that it made him uncomfortable, and that it happened all the time. The DON stated that the bathing protocol was to follow each resident’s preference for where to undress, and that the CNA had been informed of this resident’s preference. The resident’s care plan documented his need for assistance with dressing but did not include his specific bathing or undressing location preferences. Additional interviews showed that this practice extended to other residents and was not individualized based on resident choice. The CNA acknowledged awareness of the resident’s preference but stated that all residents were undressed in the shower room, while another CNA described a typical routine in which residents with limited mobility who required a mechanical lift were undressed in their rooms, covered with a blanket, and then transported to the shower room. Another resident reported seeing the first resident transported to the shower room covered only by a blanket and stated that the CNA did not ask where he preferred to undress, instead beginning to undress him after announcing it was time for a bath. A third resident stated that the same CNA transferred him from bed to a chair, covered him with a white sheet, and took him to the tub room without asking his preferences, and that he had seen other residents transported in the same manner. These practices conflicted with the facility’s Resident Dignity & Privacy Policy, which required staff to groom and dress residents according to their preferences and to maintain privacy during care.
Failure to Timely Report and Investigate Allegations of Sexual and Financial Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and initiate required investigations into two separate allegations of abuse, including sexual and possible financial abuse. One resident reported that at approximately 6:00 a.m. a contracted travel CNA placed hands down his pants while he was in bed, allegedly to check if he was wet, which the resident described as groping that made him feel cheap. The resident stated he typically did not receive nighttime incontinence checks, as he used a urinal and was usually only awakened for early morning blood sugar checks or lab draws. He reported this incident to two RNs, one of whom acknowledged that it was not appropriate for staff to put their hands down a resident’s pants to check incontinence products. Despite this, the nurses who received the allegation did not immediately report it to the DON, administrator, or state agency as required by facility policy and federal guidelines. One RN spoke with the contracted travel CNA to “educate” her but did not notify anyone else and did not know the required reporting time frame. Another RN, who was aware of the process and the two-hour reporting requirement to the state health department, also failed to promptly report the allegation to the DON or administrator, resulting in a delay until late morning before leadership became aware. At the time leadership was notified, the allegation had not yet been investigated, and law enforcement and the ombudsman had not been contacted, even though the allegation involved possible sexual abuse. A second deficiency arose when a resident’s family member reported concerns of suspected financial abuse to the social services designee, who then informed the administrator. Instead of treating this as an abuse allegation requiring reporting and investigation under the facility’s abuse and neglect policy, the administrator did not report it to the state health department, citing a lack of detailed information. The social services designee and administrator only provided the family with contact information for external agencies such as the state’s attorney and adult protective services. The facility’s own policy required that all allegations and suspicions of abuse, including misappropriation of property and exploitation, be immediately reported to the administrator or designee, investigated by the administrator or designee, and reported to the state agency within two hours, but these procedures were not followed for either the sexual abuse allegation or the suspected financial abuse concern.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
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