Medicine Wheel Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Eagle Butte, South Dakota.
- Location
- 24266 Airport Road, Eagle Butte, South Dakota 57625
- CMS Provider Number
- 43A138
- Inspections on file
- 21
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Medicine Wheel Village during CMS and state inspections, most recent first.
A CNA failed to respond appropriately to call lights and did not provide required ADL, toileting, and incontinence care to two dependent residents during a night shift. One resident, with multiple comorbidities and moderate cognitive impairment, was left without toileting assistance after using the call light, and only received help when an LPN and RN intervened. Another resident, with obesity, TBI, contracture, and documented need for two-person assist and scheduled toileting, was not checked or toileted as care-planned. Both residents were later found with heavily saturated incontinence products and urine-soaked beds, and one developed moisture-associated skin damage to the buttocks.
Staff failed to follow professional standards when a physician verbally instructed the DON to have nurses borrow a controlled medication (Lorazepam 0.5 mg) from one resident and administer it to another resident experiencing anxiety after other comfort measures failed. Because the ordered medication was not available on site, the pharmacy was closed, and the family declined ER transfer, an LPN removed a Lorazepam tablet from the first resident’s medication card and gave it to the second resident. This action bypassed facility policies requiring proper ordering, accountability, and use of controlled drugs only for the resident for whom they were prescribed, and the administrator, DON, and consultant pharmacist later acknowledged that borrowing medications between residents is not acceptable practice.
A CNA/activity staff member failed to report residents' allegations of neglect, documented during a resident council meeting, to the administrator as required by policy. This resulted in a delay of several days before the administrator and the SD DOH were notified, violating the required 24-hour reporting timeframe for such allegations.
The facility failed to provide a well-balanced diet that considered residents' preferences and dietary needs. Residents were not given meal choices, and if they refused the meal, they were only offered soup. Food portions were inconsistent due to short staffing, and the registered dietician was not informed of menu substitutions. The facility's policy to provide meals according to residents' needs and preferences was not consistently followed.
The facility failed to submit Payroll Based Journal (PBJ) data for Quarter 1, 2024, to CMS on time. The administrator and outsourced CFO were aware of the submission requirements, but a staff member from the CFO's office missed the deadline by one day. The facility's policy mandates timely submission of staffing information, which was not followed for this quarter.
The facility failed to timely report incidents involving two residents to the SD DOH. One resident experienced a knee injury during a transfer, which was not immediately documented or reported, leading to a delayed diagnosis of a tibial fracture. Another resident had an unwitnessed fall, and despite her complaints of pain, the incident was not promptly documented or reported. The DON admitted to falling behind in reporting duties, resulting in incomplete and delayed notifications to the SD DOH.
The facility failed to provide therapeutic diets as prescribed by physicians for 16 residents. Meals served did not align with approved menus, and there was no documentation or approval from the dietician for substitutions. All residents received the same meal without differentiation between their prescribed diets. The dietary manager admitted to making substitutions without notifying the dietician, and the administrator acknowledged challenges in adhering to prescribed diets due to resident preferences.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with open wounds. Staff did not wear gowns or gloves during transfers or wound care, despite the presence of EBP signage and supplies. Interviews revealed a lack of understanding of the EBP policy, with staff believing it was only necessary for residents with multi-drug resistant organisms (MDROs). The facility's policy required EBP for all residents with wounds, highlighting a discrepancy in practice.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfers, as required by regulations. The resident was transferred twice, with the POA informed but no documentation of bed hold information provided. Social services staff were unaware of the need to report each transfer, and the Ombudsman confirmed not receiving notifications.
A resident's PRN lorazepam order was not renewed beyond the 14-day limit, despite being administered 21 times over a period. The facility's policy requires PRN orders for psychotropic medications to be renewed every 14 days, but the order was not updated until after the medication had been used extensively. Interviews with the DON and an LPN revealed they were unaware of the lapse in renewal, leading to a deficiency in medication management.
A resident received food that was not prepared to the correct temperature due to a malfunctioning warming cabinet thermometer. The dietary staff did not recheck or reheat pureed meals to ensure they were above 135°F before serving. The facility's policy on food temperatures was not followed, and the maintenance department was aware of the issue for months without resolution.
Neglect of ADL and Toileting Care by CNA Resulting in Incontinence-Related Harm
Penalty
Summary
The deficiency involves a CNA’s failure to provide required ADL care and toileting assistance to two dependent residents during a night shift, resulting in neglect. On the night in question, an LPN observed that the traveling CNA repeatedly refused to answer residents’ call lights, spent time on her cell phone, and did not toilet residents or change their incontinence products. When one resident activated her call light, the CNA entered the room, turned off the call light, and left without assisting the resident. Shortly afterward, the call light was activated again, and the LPN responded, finding that the resident needed to use the bathroom and reported that the CNA would not help her. The LPN, with an RN, then assisted the resident to the toilet, provided hygiene care, and returned her to bed. The first resident involved had multiple medical conditions, including arthritis, a history of hip fracture, a chronic non‑pressure ulcer of the right lower leg, a bone density disorder, and mild dementia, with a BIMS score indicating moderately impaired cognition. Her care plan required total assistance with ADLs, dependence on staff for all transfers using a Hoyer lift, staff assistance with toileting or bedpan use, hygiene assistance as needed, and turning and repositioning every one to two hours while in bed. Despite these documented needs, the CNA did not provide the required toileting and hygiene assistance when the resident requested help via the call light, and the resident’s needs were only met when the LPN and RN intervened. The second resident involved also had significant medical and functional limitations, including obesity, arthritis, muscle weakness, encephalopathy, a history of traumatic brain injury, a left lower leg contracture, and mild dementia. His care plan indicated a self‑care deficit related to his traumatic brain injury and contracture, and required extensive assistance from two staff with a sit‑to‑stand lift, as well as two‑person assistance with toileting and hygiene. Staff were to assist him with toileting upon waking, before and after meals, at bedtime, and during night rounds. However, during the same night shift, the CNA failed to complete resident rounds or provide toileting and incontinence care. Subsequent checks revealed that both residents had heavily saturated incontinence products and urine‑soaked beds, and the second resident had redness and moisture‑associated skin damage in the buttock area, demonstrating that his scheduled toileting and hygiene interventions were not carried out as planned.
Borrowing Controlled Medication Between Residents in Violation of Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were delivered according to professional standards of quality when a controlled medication prescribed for one resident was taken and administered to another resident. On the night in question, a physician issued a new STAT order for Lorazepam 0.5 mg by mouth for a resident experiencing anxiety. The DON informed the physician that the ordered medication was not available in the facility for that resident, the distributing pharmacy was closed, and the resident’s family did not want the resident sent to the ER for evaluation. Despite this, the physician verbally instructed the DON that nurses were to borrow Lorazepam from another resident who had 0.5 mg Lorazepam tablets available in the facility. Following this instruction, the DON relayed to nursing staff that they were to use the other resident’s Lorazepam for the anxious resident when other comfort or distraction measures failed. An LPN subsequently removed a 0.5 mg Lorazepam tablet from the first resident’s medication card and administered it orally to the second resident. The medication was effective in relieving the second resident’s anxiety. The first resident’s controlled medication, which was ordered specifically for that resident, was therefore used for another resident, and the facility later arranged for the tablet to be replaced. Interviews with the administrator, DON, and consultant pharmacist confirmed that borrowing medications from one resident to administer to another is not acceptable clinical practice and does not meet professional standards of care. The administrator and DON acknowledged that the facility did not follow its own policies and procedures for medication ordering or resident treatment in this situation. Policy review showed that controlled substances are subject to special ordering, receipt, and recordkeeping requirements, and that when medications are not available, nursing staff are to notify the attending physician, explain the circumstances and available options, and obtain a new order while discontinuing the non-available medication. These established procedures were not followed when the staff borrowed one resident’s controlled medication and administered it to another resident.
Failure to Timely Report Allegations of Neglect from Resident Council
Penalty
Summary
A certified nursing assistant (CNA) who also served as activity staff attended and documented a resident council meeting where residents raised concerns about personal care, including issues such as residents appearing unkempt at meals and activities, exposure of body parts, and lack of privacy during care. These concerns were recorded as allegations of neglect in the meeting minutes. However, the CNA did not report these allegations to the administrator as required by facility policy, resulting in a delay in notifying the appropriate authorities. The administrator was not made aware of the allegations until five days after the meeting, and the South Dakota Department of Health (SD DOH) was notified six days after the initial allegations were made. Facility policies require that all allegations of abuse or neglect be reported to the administrator immediately, and to state authorities within 24 hours if there is no serious bodily injury. The failure to report the allegations in a timely manner led to noncompliance with both facility policy and regulatory requirements.
Failure to Provide Well-Balanced Diet and Consistent Meal Portions
Penalty
Summary
The facility failed to provide a well-balanced diet that considered the food preferences and dietary needs of its residents. Three residents expressed dissatisfaction with the meals provided, noting that they were not given choices or menus to select from, and if they refused the meal, they were only offered soup. One resident, who required a mechanical soft diet, received hard fruit, while another resident with diabetes and a consistent carbohydrate diet expressed dissatisfaction with the lack of meal options. The facility did not have an alternative menu, and residents were not consistently offered alternate meal options if they did not like what was served. The facility also failed to ensure that food portions were measured and consistent. During meal preparation, a CNA, who was not part of the regular kitchen staff, did not use measuring utensils to portion ham salad sandwiches, cucumbers with ranch, and three-bean salad. This inconsistency in portion sizes was attributed to short staffing and the CNA's nervousness due to the presence of surveyors. The dietary manager acknowledged the lack of an alternate meal and the absence of consistent portion sizes. The registered dietician, who was a contracted employee, did not visit the facility and was not informed of menu substitutions, which were made regularly due to food availability and resident preferences. The facility administrator acknowledged the staffing challenges and the need for documentation and dietician approval of substitutions. The facility's policy required residents to receive meals according to their needs and preferences, but this was not consistently followed, leading to the deficiency.
Failure to Submit PBJ Data on Time
Penalty
Summary
The provider failed to submit their Payroll Based Journal (PBJ) data for Quarter 1, 2024, to the Center for Medicare and Medicaid Services (CMS) as required. The review of the Certification and Survey Provider Enhanced Reports (CASPER) data revealed that no PBJ data was submitted for the period from October 1, 2023, through December 31, 2023. This deficiency was identified during an interview with the facility's administrator, who acknowledged the requirement to submit the data and the existence of deadlines. The administrator indicated that a vendor was responsible for tracking payroll and PBJ data, but the vendor missed the submission deadline. Further interviews with the administrator and the outsourced chief financial officer (CFO) revealed that the CFO's office was responsible for ensuring the PBJ data was submitted to CMS. A staff member from the CFO's office failed to submit the data by the deadline, missing it by one day. Both the administrator and the CFO expected the data to be submitted on time each quarter. The facility's policy, revised on January 4, 2023, stated that it is their policy to submit complete and accurate staffing information to CMS in a timely manner, but this was not adhered to for the specified quarter.
Failure to Timely Report Incidents to SD DOH
Penalty
Summary
The provider failed to provide timely and thorough notification to the South Dakota Department of Health (SD DOH) regarding incidents involving two residents. Resident 2 reported hearing a pop in her knee during a transfer, which was not immediately documented in the nurse's progress notes. Despite experiencing significant pain and swelling, the resident was not sent to the emergency room until two days later, and this information was omitted from the facility's initial and final reports to the SD DOH. The resident was eventually diagnosed with a proximal right tibial fracture, but the details of her hospital visit and diagnosis were not included in the final report. Resident 6 experienced an unwitnessed fall and was found sitting on the floor. Although she reported pain and requested medical attention, there was no immediate documentation of the fall in the nurse's progress notes. The resident's family requested an x-ray due to her complaints of pain, leading to her transfer to the emergency room. However, this information was not included in the initial report submitted to the SD DOH, and the final report was not submitted on time. The Director of Nursing (DON) admitted to not reporting the incidents in a timely manner, citing a lack of information and falling behind in reporting duties. The facility's policy requires immediate notification of the administrator and reporting to the SD DOH within two hours of forming a reasonable suspicion of a crime or injury of unknown source. The DON acknowledged awareness of these guidelines but failed to adhere to them, resulting in incomplete and delayed reporting of the incidents involving residents 2 and 6.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as prescribed by physicians for 16 out of 21 residents. Observations revealed that meals served did not align with the approved scheduled menu items, and there was no documentation or approval from the dietician for these substitutions. All residents received the same meal without differentiation between their individually prescribed diets, which included regular, heart healthy, renal, consistent carbohydrate, and no added salt diets. The dietary manager admitted to making substitutions due to the unavailability of menu items and personal preferences of the residents, without notifying or obtaining approval from the dietician. Interviews with the registered dietician and the facility administrator confirmed that the kitchen staff did not follow the approved menus and failed to document substitutions. The dietician expressed concerns about not being informed of menu changes, and the administrator acknowledged challenges in adhering to prescribed diets due to resident preferences and complaints from elderly protection. A review of dietary orders showed that specific dietary needs were not addressed for several residents, including those requiring consistent carbohydrate, heart healthy, no added salt, and renal diets.
Failure to Implement Enhanced Barrier Precautions for Residents with Open Wounds
Penalty
Summary
The provider failed to ensure that two residents with open wounds were placed on enhanced barrier precautions (EBP). Observations revealed that staff members did not wear gowns or gloves when entering the room of a resident who required the use of a Hoyer lift for transfers. Despite the presence of a sign indicating the need for EBP and available supplies, these were not visible when the door was open. Interviews with the resident and a certified nursing assistant (CNA) confirmed that gowns and gloves were not used during transfers. The resident's electronic medical record indicated a dressing for a chronic ulcer on the right leg. Another resident with an open wound on the left foot also did not have EBP signage or supplies near the door. Staff members did not wear gowns during transfers or while providing wound care, although gloves were used during bandage changes. Interviews with a licensed practical nurse (LPN) revealed a lack of knowledge about the facility's EBP policy, with the LPN believing that EBP was only necessary for residents with multi-drug resistant organisms (MDROs). The infection control registered nurse (ICRN) also indicated that EBP was only expected for wounds with MDROs or uncontainable seepage, contrary to the facility's policy that required EBP for all residents with wounds.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The provider failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospital transfers of a resident, identified as resident 13. The resident was transferred to the hospital on two occasions, once on January 29, 2024, and again on September 11, 2024. In both instances, while the resident's power of attorney (POA) was informed of the transfers, there was no documentation indicating that bed hold information was provided to either the resident or the POA. Furthermore, the facility did not send a copy of the transfer notice to the Ombudsman as required by regulations. Interviews with the facility's social services staff revealed a lack of awareness regarding the requirement to notify the Ombudsman of every hospital transfer. The social services department, responsible for these notifications, admitted to sometimes using email or phone calls for communication but did not consistently follow the protocol. The local Ombudsman confirmed not receiving notifications for the resident's transfers and had previously discussed the regulation with the facility's social services staff. Despite this, no documentation was available to verify that the Ombudsman was informed of the transfers, indicating a failure in the facility's notification process.
Failure to Renew PRN Lorazepam Order
Penalty
Summary
The provider failed to ensure that a resident's as-needed (PRN) lorazepam order was renewed for continued use beyond the 14-day limit. The resident had a physician's order for lorazepam to be administered every four hours as needed for increased anxiety and tooth pain. Despite the facility's policy requiring PRN orders for psychotropic medications to be renewed every 14 days, the order was not renewed, and the medication was administered 21 times from August 15 to September 30. The physician's response to extend the PRN order indefinitely was not documented until September 30, and the director of nursing signed it on October 2, indicating a lapse in compliance with the policy. Interviews with the director of nursing and a restorative LPN revealed that they were aware of the requirement for PRN lorazepam orders to be renewed every 14 days but were not aware that the order had not been renewed. The facility's policy on psychotropic medication use emphasizes the need for gradual dose reductions and limits PRN orders to 14 days unless a prescriber documents the rationale for extending the order. The failure to renew the PRN lorazepam order as required by policy resulted in a deficiency in the facility's medication management practices.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that a resident received food prepared to the correct temperature, as observed during a survey. The kitchen warming cabinet's thermometer was not functioning, and the temperature control dial was set at varying levels, which were not verified for accuracy. The dietary manager and cook both prepared pureed meals for the resident using warm broth, but did not recheck or reheat the food to ensure it was at a safe temperature before serving. The temperatures of the pureed foods were recorded to be below the required 135 degrees Fahrenheit, with some items as low as 107.9 degrees Fahrenheit. The facility's food preparation and service policy was not followed, as the danger zone for food temperatures was not avoided, and there was no internal thermometer in the warming cabinet to ensure safe food temperatures. The maintenance department was aware of the broken thermometer for two to three months, but a new warming cabinet was only ordered recently. The administrator was also recently informed of the issue and expected the facility's policies to be adhered to. The facility's food temperature log showed that while cooked food temperatures were documented after cooking, there was no record of temperatures being checked after pureeing and before serving.
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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