Good Samaritan Society Sioux Falls Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux Falls, South Dakota.
- Location
- 401 West Second Street, Sioux Falls, South Dakota 57104
- CMS Provider Number
- 435046
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Good Samaritan Society Sioux Falls Center during CMS and state inspections, most recent first.
A CNA verbally abused three residents during nighttime care interactions. One resident with moderate cognitive impairment and end-stage renal disease reported that the CNA responded to his call light with profanity and a hostile attitude when he requested help after a bowel movement. Another cognitively intact resident with multiple sclerosis stated that when she requested a female staff member to assist her into bed, the CNA became upset, left, and slammed her door, and she later heard the CNA arguing with a third resident who was crying. That third resident, who had quadriplegia and a colostomy, reported that the CNA did not know how to empty his colostomy bag, refused to get help from another staff member, shouted at him in a non-English language, and left the room, after which the resident was found crying and expressing emotional distress.
Staff did not ensure that four residents received regular weekly bathing and hygiene care according to facility expectations and resident needs. One resident with CHF and hypothyroidism was found in a room with a strong urine odor, urine‑stained bedding, and signs of poor hygiene, and records showed more than three weeks between documented baths without any refusals. Three other residents reported or demonstrated missed baths, with documentation revealing gaps of 14 to 21 days between baths or showers and no recorded refusals. During a period when the full‑time bath aide was on vacation, the DON and administrator stated that weekly baths were expected and that coverage was planned, but the bath aide reported residents sometimes did not receive baths when she was reassigned, and staffing schedules showed multiple weekdays with no staff assigned to provide baths, despite a policy emphasizing bathing for hygiene, comfort, observation, and safety.
The facility failed to control smoking-related hazards and provide required supervision for multiple residents who smoked. Several residents assessed or care planned as needing supervision, smoking aprons, and in one case oxygen removal before smoking, were allowed to access the courtyard and front entrance areas to smoke without staff knowledge or direct oversight. A resident with MS, paraplegia, intellectual disability, and moderately impaired cognition, who had a prior unsafe smoking incident and was care planned to be accompanied by staff, went to the courtyard at night with another resident who knew the door code; his hat brim contacted a lit cigarette, causing smoldering and singeing of his beard and facial areas before staff were informed. Other residents, including those using power wheelchairs and one on oxygen, reported or were observed smoking independently in the courtyard with only intermittent visual checks from staff inside, or outside the front doors without signing out or notifying staff, while keeping their own lighters despite care plan directions. Staff interviews and observations showed inconsistent enforcement of smoking rules, incomplete or outdated Tobacco Use Evaluations, and care plans that did not align with actual practice, resulting in inadequate supervision of residents who required monitored smoking.
A resident slipped from a wheelchair, complained of left hip pain, and a portable X-ray later confirmed a left intertrochanteric femur fracture. The DON and administrator, who were responsible for incident reporting, knew that a confirmed hip fracture diagnosed by an in-house X-ray constituted a serious bodily injury requiring notification to the SD DOH within 2 hours, per the facility’s abuse and neglect policy. However, they delayed reporting and instead submitted the Facility Reported Incident several hours later, applying a 24-hour reporting standard tied to outside medical attention rather than the 2-hour requirement for serious bodily injury.
A resident with incontinence, an open wound, and multiple comorbidities experienced repeated delays in staff response to call lights, sometimes waiting over an hour for assistance. These delays resulted in the resident remaining in soiled conditions, contributing to emotional distress and discomfort. Facility records and staff interviews confirmed inconsistent expectations for call light response times, and the facility's policies requiring prompt assistance were not followed, resulting in neglect.
Staff initiated CPR on a resident with a documented DNR order after relying on incorrect verbal confirmation of code status from other staff, rather than verifying the advance directives binder or EMR as required by facility policy. The DNR order was only discovered after CPR had begun and EMS arrived.
The facility failed to ensure proper food labeling and storage, maintain dishwashing temperatures, and enforce hand hygiene practices. Observations revealed unlabeled food items in the walk-in cooler, dishwashing temperatures below the required 120°F, and dietary staff not washing hands between tasks. These actions violated the facility's policies on food storage, dishwashing, and hand hygiene.
A facility failed to follow infection control practices during G-tube administration and did not implement contact precautions for a resident tested for C-Diff. An LPN did not change gloves between tasks and used unsanitized surfaces, while staff were unaware of the need for C-Diff precautions, leading to inadequate infection control measures.
The facility failed to discard expired medications, with seven bottles of expired aspirin found in the medication cart and storeroom. CMAs confirmed the oversight, and the DON expressed frustration over missing these during monthly checks. The facility's policy requires routine checks and proper labeling of medications.
The facility failed to provide meals that met the dietary preferences and needs of residents, as observed during two meal services. A resident on a heart-healthy diet expressed concerns about meal appropriateness, and another resident did not receive the ordered meal without being informed or offered an alternative. Dietary cards were not used, leading to uniform meal service regardless of individual needs. Breakfast service was delayed, with missing menu items and unavailable condiments, highlighting a lack of coordination in meal delivery.
Failure to Protect Residents From Verbal Abuse by CNA
Penalty
Summary
Non-compliance at F600 occurred when the provider failed to protect three residents from verbal abuse by a CNA. On the night of 3/3/26, a resident with moderate cognitive impairment, an above-the-knee amputation, and end-stage renal disease requiring dialysis activated his call light after a bowel movement. When the CNA responded, he reportedly displayed a bad attitude and asked the resident, using profanity, what he wanted. The resident became angry and told the CNA to leave his room. This interaction was later reported by the resident to an LPN. Around the same time, another cognitively intact resident with multiple sclerosis activated her call light for assistance getting into bed. When the CNA arrived, she requested a female staff member to help her. The CNA became upset, left the room, and slammed the resident’s door. The resident reported hearing the CNA arguing with a third resident across the hall and hearing that resident crying shortly thereafter. The third resident, who had moderate cognitive impairment, quadriplegia, and a colostomy, had requested assistance with emptying his colostomy bag. The CNA did not know how to perform the task, and when the resident asked him to find another staff member to help, the CNA refused to seek assistance. The CNA then began shouting at the resident in a non-English language and left the room. The resident was later found crying by the LPN and expressed emotional distress, including apologizing for being alive and feeling like a burden. These events were reported to the administrator, and an investigation confirmed the residents’ allegations of verbal abuse by the CNA.
Failure to Provide Scheduled Weekly Bathing and Hygiene Care
Penalty
Summary
Staff failed to provide scheduled bathing and hygiene care to four sampled residents over the months of February and March 2026. One resident was observed with a strong urine odor emanating from his closed room, with the smell intensifying when the door was opened. His bed contained large urine stains on the sheets and incontinence pad, and he appeared not to have bathed in some time, with dry, flaky skin and greasy, tangled hair. He reported needing assistance with bathing and expressed a desire to bathe more than once per week, noting that Thursdays were his scheduled bath days. His care plan identified an ADL self-care performance deficit related to CHF and hypothyroidism, with interventions indicating he required assistance of one staff member for bathing and personal hygiene, but the care plan did not document his bathing or showering preferences or frequency. Record review showed that this resident received a whirlpool bath on 2/24/26 and then not again until 3/19/26, indicating a 23‑day gap without a documented bath, bed bath, or shower, and there were no documented refusals during this period. Another resident reported missing showers in recent weeks, explaining that the bath aide had been gone for two weeks and that he also missed a bath due to an appointment; he stated he felt "gross" before being bathed on 3/18/26. His records showed a whirlpool bath on 2/18/26 and the next on 3/18/26, a 16‑day interval without documented bathing or refusals. A third resident stated he did not always receive baths as scheduled and that sometimes there was no bath aide available; his documentation showed a whirlpool bath on 2/20/26 and then a bed bath on 3/6/26, a 14‑day gap without documented bathing or refusals. A fourth resident’s bathing record showed a shower on 2/24/26 and the next on 3/17/26, a 21‑day period without a documented bath, bed bath, or shower and no documented refusals. The interim DON stated residents were to receive a bath each week and that when the full‑time bath aide was on vacation, CNAs were assigned to provide scheduled baths. The administrator also stated he expected residents to receive a weekly bath and that there was a plan to ensure this when the bath aide was on vacation, though he did not specify the plan. The bath aide reported she was responsible for bathing 14 residents per day, that residents were scheduled for baths Monday through Friday, that she was on vacation from 2/23/26 through 3/8/26, and that when she was reassigned to CNA duties, residents did not receive baths. Review of the staff schedule for the bath aide’s vacation period showed that on five of ten weekdays no staff member was assigned to provide resident baths, despite a facility bathing policy emphasizing cleanliness, hygiene, circulation, comfort, observation of resident condition, assistance with personal care, and safety.
Failure to Supervise Resident Smoking and Control Smoking Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure a smoking environment free from accident hazards and to provide adequate supervision for residents who required supervision while smoking. Multiple residents who smoked were assessed or care planned as needing supervision, smoking aprons, and in some cases removal of oxygen prior to smoking, yet they were routinely allowed to access smoking areas or leave the building to smoke without staff knowledge or direct oversight. Residents knew door codes to both the courtyard and front entrance, used those codes without informing staff, and smoked in locations and at times outside the designated supervised smoking periods. Staff interviews confirmed that residents commonly kept their own cigarettes and lighters, that some refused to store lighters at the nurses’ station despite care plan directions, and that residents went out the front doors to smoke without notifying staff or signing out. One resident with multiple sclerosis, paraplegia, intellectual disability, moderately impaired cognition (BIMS 11), and a prior history of burning clothing was care planned to require a smoking apron, supervision, and staff accompaniment when smoking. His tobacco assessment documented prior unsafe smoking behavior and the need for supervision and adaptive equipment. Despite this, he was able to go to the enclosed courtyard at night with another resident who knew the door code, without informing staff. While wearing a brimmed hat and attempting to smoke, the hat brim contacted the lit cigarette, began smoldering, and singed his beard and facial areas. Camera footage showed that the two residents remained outside to finish smoking and only reported the incident to the RN after returning inside, at which time a skin assessment revealed reddened but intact skin on his head and face. Other residents who were assessed or care planned as requiring supervision while smoking also smoked without adequate supervision or adherence to facility protocols. One cognitively intact resident, assessed as needing a smoking apron and supervision, was observed outside the front door in his power wheelchair picking up cigarette butts with a reacher, without having signed out and without staff present. Another resident, also assessed as needing supervision and a smoking apron, reported smoking in the courtyard or outside the front doors whenever he wanted, keeping his cigarettes and lighter with him and not informing staff or signing out. Additional residents, including one on oxygen and others with intact cognition but care plans requiring supervision and smoking aprons, described or were observed smoking in the courtyard with only intermittent visual checks from staff inside the activities room, or smoking outside the front doors in the evenings without staff awareness, sign-out, or consistent enforcement of lighter storage and supervision requirements. Staff interviews and observations further demonstrated inconsistent implementation of supervision expectations. Activities staff and CMAs acknowledged that residents 2 and 3 routinely went out the front doors to smoke without staff assistance, that most residents kept their own lighters despite some care plans directing storage at the nurses’ station, and that staff did not remain continuously at the courtyard door while residents smoked. During observed smoking periods, activities staff opened the courtyard door, then returned to desks behind a partition, performed other tasks, or only occasionally glanced out the window while multiple residents who required supervision smoked outside. In at least one instance, an activities assistant stood several feet from the door reading a book and intermittently left the doorway area while a resident smoked alone in the courtyard. The DON and MDS nurse both stated that residents 1, 2, 3, 4, 5, 7, and 8 required supervision when smoking in the courtyard, and that staff were expected to be outside with residents or at the window providing constant supervision, but observations and interviews showed that this level of supervision was not consistently provided. The facility’s documentation and assessment processes related to smoking also contributed to the deficiency. Tobacco Use Evaluations were not consistently completed quarterly or annually as described by the MDS nurse, with gaps noted for several residents, and some evaluations did not clearly specify the level of supervision required. Care plans documented that certain residents were independent with tobacco use while simultaneously listing interventions requiring supervision, smoking aprons, and removal of oxygen, creating inconsistencies between assessed needs and described independence. The DON acknowledged that the Tobacco Use Evaluation addressed smoking on facility property but did not address residents’ independent smoking off property, even though residents in power wheelchairs were leaving the building in cold weather to smoke without documented assessment of their safety in doing so. These combined assessment, care planning, and supervision failures led to residents who required supervision while smoking being unsafely allowed to smoke with inadequate staff oversight, culminating in at least one resident sustaining facial burns.
Failure to Timely Report Serious Bodily Injury to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report a known serious bodily injury to the South Dakota Department of Health (SD DOH) within the required 2-hour timeframe. A resident slipped from her wheelchair onto her left hip and complained of left hip pain in the afternoon. A portable X-ray was obtained, and by early evening a registered nurse documented that the X-ray results showed a left intertrochanteric femur fracture, and the results were faxed to the physician. The resident’s family initially delayed transfer to the emergency department (ED) while they discussed options, and the resident was ultimately transferred to the ED the following morning, admitted to the hospital, and later died. The facility’s Facility Reported Incident (FRI) to SD DOH was not submitted until late that same morning. Interviews and policy review showed that the DON and administrator were responsible for reporting incidents to SD DOH and were aware that a confirmed hip fracture, even when diagnosed via portable X-ray in the facility, constituted a serious bodily injury that must be reported within two hours of the allegation or identification. The DON stated that reporting after outside medical attention was to occur within 24 hours, but also acknowledged that a confirmed hip fracture required reporting within two hours. The administrator reported he believed that because the resident did not receive outside medical attention immediately after the fall, the incident fell under the 24-hour reporting requirement. The facility’s Abuse and Neglect policy specified that any allegation involving serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. Despite this policy and knowledge that a hip fracture is a serious bodily injury, the facility did not report the incident to SD DOH within the required 2-hour timeframe after the fracture was confirmed.
Failure to Protect Resident from Neglect Due to Delayed Call Light Response
Penalty
Summary
A resident with multiple medical conditions, including mixed incontinence, an open wound on the right buttock, spinal stenosis, morbid obesity, and mental health diagnoses, experienced prolonged wait times for staff response to call lights. The resident, who was bedfast and had a history of refusing some care, reported several instances where call lights were not answered for periods ranging from over 20 minutes to more than an hour. During these times, the resident was left incontinent of urine or bowel, which contributed to feelings of humiliation and discomfort. Documentation confirmed that the resident's call light was left unanswered for extended periods on multiple occasions, as evidenced by the facility's call light log and the resident's own statements during interviews. The resident's care plan indicated a need for significant assistance, including daily wound care and regular toileting, due to his risk for skin breakdown and incontinence. Despite these needs, staff interviews revealed inconsistent expectations regarding timely call light response, with some staff expecting a two-minute response and others considering 20 to 30 minutes as prompt. The resident's medical record also showed a Braden score indicating mild risk for skin breakdown and a BIMS score reflecting intact cognition, supporting the resident's ability to accurately report his experiences. Facility policies required prompt response to call lights and protection from neglect, but the documented delays in responding to the resident's requests for assistance resulted in the resident remaining in soiled conditions for extended periods. Staff interviews acknowledged the resident's distress and the impact of delayed care, while administrative staff provided varying definitions of what constituted an appropriate response time. These actions and inactions led to the resident experiencing neglect, as defined by the facility's own policies and regulatory standards.
Failure to Withhold CPR for Resident with DNR Order
Penalty
Summary
Facility staff failed to withhold cardiopulmonary resuscitation (CPR) for a resident who had a documented do not resuscitate (DNR) order. The resident was found unresponsive by a restorative nursing aide, and the Director of Nursing (DON) initiated the facility's code blue process. CPR was started based on verbal confirmation from a certified nursing assistant (CNA) and a registered nurse (RN) that the resident was a full code, without first verifying the resident's code status in the advance directives binder or electronic medical record. The DNR order was only discovered after CPR had already been initiated and emergency medical services (EMS) had arrived. Interviews revealed that staff were trained to check the advance directives binder and the resident's electronic medical record to confirm code status before starting CPR, as per facility policy. However, in this incident, the CNA and RN provided incorrect verbal information regarding the resident's code status, and the DON relied on this information rather than verifying the DNR order. The facility's policy required confirmation of code status prior to initiating CPR, but this step was not followed, resulting in CPR being performed on a resident with a valid DNR order.
Deficiencies in Food Storage, Dishwashing, and Hand Hygiene
Penalty
Summary
The provider failed to ensure proper food labeling and storage in the kitchen's walk-in cooler. Observations revealed multiple opened food items, such as mayonnaise, BBQ sauce, Dijon mustard, coleslaw dressing, balsamic vinegar, tuna salad, whipped topping, and blue cheese, without appropriate open or discard dates. Additionally, opened containers of milk and heavy whipping cream were found without open or discard dates. These findings indicate a lack of adherence to the facility's food and supply storage policy, which requires labeling and dating of unused portions and open packages. The dishwashing machine's water temperature was not maintained at the required minimum of 120 degrees Fahrenheit for effective cleaning and disinfecting of dishes. Observations and testing showed that the wash cycle temperatures ranged from 113 to 120 degrees Fahrenheit, with some days lacking documented temperatures. Dietary staff were unsure of the policy for obtaining dishwasher temperatures, and the kitchen general manager noted that the dishwasher rarely reached the required temperature. This failure to maintain proper dishwashing temperatures is contrary to the facility's dishmachine temperatures policy. Dietary staff, including the dietary director and a cook, did not perform appropriate hand hygiene during meal service. The dietary director was observed handling eggs and egg shells with gloves, then touching resident plates and food without changing gloves or washing hands. Similarly, the cook handled eggs and bacon with the same gloves, without washing hands between tasks. Both staff members were uncertain about the facility's hand hygiene policy, which mandates handwashing after glove removal. These actions demonstrate a failure to adhere to the facility's hand hygiene policy, compromising food safety and sanitation.
Infection Control Deficiencies in G-Tube Administration and C-Diff Precautions
Penalty
Summary
The provider failed to ensure proper infection control practices during the administration of nutritional formula and fluids through a gastric tube (G-tube) for a resident. An LPN was observed performing several tasks without changing gloves, such as retrieving items from a medication cart and moving a chair, and did not sanitize the overbed table before placing supplies on it. The LPN also failed to check the placement of the G-tube before administering water and used gloves stored in a pocket with keys and a pen, which compromised the sterility of the procedure. Additionally, the provider did not implement appropriate contact precautions for a resident tested for Clostridium difficile (C-Diff). There was no signage on the resident's door indicating the need for contact precautions, and specific trash or laundry bins were not provided in the room. Staff members, including a registered nurse, laundry technician, and environmental services technician, were unaware of the resident's C-Diff testing and the necessary precautions, leading to a lack of proper infection control measures. The facility's policies on C-Diff and standard transmission-based precautions were not followed. The policy required informing all department directors when a C-Diff infection was identified, using appropriate personal protective equipment (PPE), and cleaning with a sporicidal disinfectant or bleach solution. However, these measures were not implemented, and the cleaning product used was not effective against C-Diff. The DON confirmed that contact precautions should have been initiated when the order for testing was received.
Expired Medications Not Discarded
Penalty
Summary
The facility failed to ensure that expired medications were appropriately discarded, as observed during a survey. On the medication cart for city view residents and in the second-floor medication storeroom, seven bottles of expired aspirin were found. Specifically, two of the three bottles of 325 mg aspirin in the medication cart were expired, with expiration dates of January and February 2024. Additionally, four out of eleven bottles of 81 mg chewable aspirin in the storeroom cupboard had expired in May 2024. Certified Medication Aides (CMAs) confirmed the expiration dates and acknowledged that medications should be checked for expiration before administration. The Director of Nursing expressed frustration over missing the expired medications during her monthly checks of stock medications in the carts and storeroom. She emphasized that all staff responsible for administering medications should check expiration dates before giving them to residents. The facility's medication policy, dated March 29, 2024, requires routine checks for expired medications and their disposal according to state and pharmacy regulations. It also mandates that all medications be labeled with cautionary instructions and expiration dates, with new labels applied by a pharmacist or their agent as needed.
Failure to Meet Residents' Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide meals that met the dietary preferences and needs of residents, as observed during two meal services. Resident 335, who was supposed to be on a heart-healthy diet, expressed uncertainty about the healthiness of her meals, citing an instance where she received macaroni and cheese, pork and beans, a bun, and dessert, which she did not consider heart-healthy. Additionally, she noted that staff were reluctant to retrieve forgotten items from the main kitchen, such as ketchup. During a meal observation, all residents received the same meal, and dietary cards indicating individual dietary needs and preferences were not utilized. Resident 33, who had ordered chicken strips, fries, and coleslaw, was served a different meal without prior notice or an alternative being offered. Further observations revealed that during breakfast service, the food was brought to the dining room without staff present to serve it, resulting in delays. The menu items served did not match the listed menu, with missing items such as fruit cups and whole wheat toast. Condiments were also unavailable, and dietary server H did not use dietary cards to ensure residents received the correct meals. Residents 33 and 71 experienced delays in receiving their meals, which were left on the counter until reheated by CNA R. CNA G was unable to retrieve requested brown sugar for residents 46 and 335 due to other duties, highlighting a lack of coordination and communication in meal service delivery.
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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