Palisade Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garretson, South Dakota.
- Location
- 920 4th St, Garretson, South Dakota 57030
- CMS Provider Number
- 435115
- Inspections on file
- 26
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Palisade Healthcare Center during CMS and state inspections, most recent first.
Multiple residents with incontinence, impaired mobility, and high pressure-injury risk were not changed or repositioned as ordered or expected, resulting in prolonged periods in wet briefs, extended time in the same position, and failure to use pressure-relieving measures such as heel elevation. One resident with a history of coccyx pressure injury had a previously healed area reopened when a CNA cleaned the area roughly with a dry wipe and spray, causing a stage II ulcer, while another resident developed bright red, superficially open perineal and inner thigh areas after reporting that his brief had not been changed for a long time and that call lights often went unanswered for hours. Additional residents reported or were observed experiencing delayed toileting assistance, call lights out of reach, rough or non-communicative care, and refusal or failure by CNAs to provide requested hygiene or clothing changes, demonstrating neglect of basic care needs and, in one instance, abusive rough perineal care.
Surveyors found that call lights, used by residents to request staff assistance, were repeatedly left out of reach for multiple residents in bed, including one who reported never having access to her call light and another who was calling out for help to use the bathroom while her call light lay at the foot of the bed despite high fall-risk signage. Observations showed call lights hung over headboards, clipped to wall cords, lying near the floor, or placed on tables and recliners away from residents, while CNAs, a CMA, an RN, an LPN, and the administrator all acknowledged that call lights were expected to be within residents’ reach but were not in these instances.
A resident with urinary retention, bladder disorder, and a suprapubic catheter was ordered to have twice-daily catheter flushes with normal saline and 5% vinegar. An LPN reported reusing a labeled graduated cylinder for the irrigation solution while only changing the syringe, despite facility policy requiring sterile equipment and the availability of sterile catheter kits. The DON acknowledged the container should be changed each time and that the resident had experienced UTIs, while a nurse manager training as the infection preventionist was unaware non-sterile cylinders were being used. The administrator stated the LPN had been educated on catheter kits and that nurses should understand sterile field requirements.
A resident with multiple comorbidities and a history of pressure ulcers developed new wounds on the lower legs and foot. Staff failed to promptly assess, document, and communicate these wounds, leading to delays in treatment and a lack of timely interventions. Inaccurate information was sent to the physician, and several days passed without care for the wounds, resulting in the resident's condition worsening and requiring hospitalization. Facility policies for skin integrity monitoring and response were not followed, contributing to the deficiency.
A resident with quadriplegia and a prior cervical spine fracture was injured during a transfer when an LPN and a CMA/CNA used an incorrectly sized full-body lift sling, resulting in a fall and a hematoma. Staff used multiple brands of slings but relied on a single sizing chart, disregarding manufacturer-specific sizing requirements. The facility lacked policies for assessing and documenting appropriate sling size, and several residents were observed using slings of undetermined or potentially incorrect sizes.
Two residents at risk for pressure ulcers did not receive timely or adequate preventive interventions, resulting in the development of new pressure ulcers. In both cases, required measures such as heel boots, pressure-reducing mattresses, and frequent repositioning were either delayed, inconsistently applied, or not documented as performed. Staff interviews and record reviews confirmed that care plans and facility policies for skin integrity were not followed prior to the onset of the ulcers.
Multiple residents experienced significant delays in call light response, with some waiting up to two hours for assistance. Audit data and interviews confirmed that staff did not consistently meet the expected response time of three to five minutes, and residents with high care needs were particularly affected. The facility lacked a formal call light response policy, and both resident council minutes and grievances documented ongoing concerns about long wait times and short staffing.
Drugs and biologicals were not labeled in accordance with professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Multiple residents reported that meals were frequently served cold, especially to those eating in their rooms or served last in the dining room. Food was often unappetizing, and menu substitutions were common due to shortages, with residents not consistently receiving updated menus. Staff confirmed that menu distribution had stopped, and observations showed food temperatures below policy standards. Resident council minutes and grievances documented ongoing dissatisfaction with food quality, service delays, and lack of communication about meal options.
Staff failed to consistently perform hand hygiene, use gloves and gowns, and follow contact and enhanced barrier precautions during resident care, including wound care and care for residents with C. difficile and pressure ulcers. Clean supply fields were contaminated, mechanical lifts were not sanitized between uses, and hand hygiene supplies were often unavailable or nonfunctional in resident rooms and bathrooms. Staff were sometimes unaware of proper protocols or the location of PPE, and housekeeping did not routinely check or refill hygiene supplies.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required.
The facility failed to provide required Medicare notices using the current forms and did not ensure proper completion and documentation for two residents discharged from Medicare Part A skilled services. One resident received an outdated NOMNC form missing the non-discrimination clause, while another's NOMNC was unsigned and undated, and the SNF ABN lacked a specific explanation and provider identification for verbal notification.
A resident with dementia and other conditions fell from his wheelchair due to unlocked brakes, resulting in a head laceration. The facility failed to update his care plan to include an anti-roll back bracket intervention, despite a maintenance ticket being placed. The resident was later found in the wrong chair, and the intervention was missed in the care plan update.
A resident with cognitive impairments fell and sustained a head injury when attempting to self-transfer from a wheelchair lacking an anti-roll back bracket. The facility failed to ensure the resident's safety by not updating the care plan to include this intervention, and the resident was found using a different wheelchair without the necessary safety feature.
A resident with psoriasis did not receive physician-ordered leg care, despite documentation by an LPN indicating otherwise. Family members discovered poor hygiene, saturated socks, and maggots on the resident's feet. Assessment by the DON and wound nurse confirmed untreated skin issues and improper care, including the use of vinegar not ordered by a physician. These actions and omissions constituted neglect as defined by facility policy.
A resident with multiple chronic conditions and physician-ordered skin treatments did not have their care plan updated to reflect specific orders for daily dressing changes and compression wraps. Although detailed orders and assessments were present in the medical record, the care plan only included general skin care interventions and omitted the individualized treatments prescribed by the physician. Staff interviews confirmed the absence of a formal care plan policy and that updates were not consistently made.
A CMA failed to administer Sevelamer HCL according to pharmacy directions for a resident with end-stage renal disease. Despite a label indicating not to crush, the CMA crushed the medication and mixed it with applesauce, leaving the resident before ensuring ingestion. The DON was unaware of this practice, which was against facility policy.
Neglect of Incontinence Care, Repositioning, and Rough Perineal Care Leading to Skin Breakdown
Penalty
Summary
The deficiency involves multiple failures to protect residents from neglect and abuse, primarily related to untimely incontinence care, inadequate repositioning, and rough handling during perineal care. Several residents with high risk for pressure injuries and impaired mobility were not changed or repositioned according to their care plans or leadership expectations. One cognitively intact resident with a high Braden risk score and a history of pressure ulcers was documented and confirmed by staff to have gone approximately four to four and a half hours without being changed or repositioned, despite care plan expectations for frequent repositioning and incontinence care with barrier cream. Observations showed this resident lying on her back for extended periods, with a wet brief and lift sheet, slightly red groin and buttocks, and heels not propped on pillows as ordered. CNA staff acknowledged that the resident should have been changed and repositioned every two hours and that this was not done or documented as required. Another resident with moderately impaired cognition, a Braden score indicating risk for pressure ulcers, and an existing stage IV coccyx pressure ulcer was not repositioned or changed for several hours, contrary to care plan directions for routine side-to-side repositioning, heel elevation, frequent toileting, and barrier cream use. Observations showed this resident remaining on the same side or on her back for extended periods between documented care episodes. A nurse later stated that this resident was not to be positioned on her back due to the stage IV coccyx ulcer. The resident also reported that a CNA had been rough and non-communicative during night care and had refused to change her shirt when requested, and surveyors observed her wearing the same shirt from the previous day, with heel boots sliding off and heels resting on the bed while she complained of heel pain. A third resident with severe cognitive impairment, high pressure-ulcer risk, incontinence, and a history of coccyx pressure injury reported feeling that her brief was "flooded" and her bottom was sore, and that some staff were rough during care. Her care plan required frequent toileting, barrier cream, use of a lift sheet, and pressure-relieving devices. A hospice RN expected repositioning and incontinence care every two hours. However, CNA documentation and interviews showed that she was not consistently changed or repositioned every two hours, and her Kardex did not specify the required frequency. In addition, an incident occurred in which a CNA cleaned her coccyx area roughly with a dry wipe and cleansing spray, reopening a previously healed fragile area and resulting in a stage II coccyx ulcer; another CNA had to physically intervene to stop the rough cleaning. Further neglect was identified for a resident with quadriplegia, urinary incontinence, high pressure-injury risk, and an air mattress and heel boots ordered. This resident reported that his call light was sometimes unanswered for two to four hours and that his brief had not been changed for a long period on at least one occasion, causing him to sit in urine long enough to develop skin irritation and open sores in the perineal area. Subsequent wound care observations confirmed bright red perineal, inner thigh, and rectal skin with superficial open areas, and the resident stated the sores had been present for a few weeks. The nurse stated CNAs were supposed to check him every two hours, and his care plan required routine turning, ensuring he was clean and dry, and use of barrier cream. Another resident with moderately impaired cognition, stroke-related deficits, and a care plan requiring one staff for bed mobility and personal hygiene, use of a bedpan, perineal cleansing after each incontinent episode, and a call light within reach was observed repeatedly calling out for help. A CNA entered and exited the room, stating the resident wanted to get up or needed the bathroom, but left to find help without providing immediate assistance. When another CNA responded, the resident appeared restless, had a wet brief, and stated she needed to use the bathroom and that no one would help her. Her call light was found at the foot of the bed despite posted signs directing that it be attached to the bed due to her high fall risk. The report also documents resident complaints and staff observations related to disrespectful and neglectful behavior by certain CNAs. One resident reported that a night-shift CNA refused to provide a blanket, was rude when asked for repositioning, and remained on the phone speaking another language during personal care, causing the resident to feel afraid of the CNA and unsure when she might lose her temper. Another resident reported that her incontinence product was not changed overnight and that she did not have access to her call light to request assistance. A CNA reported that a staff member had been sleeping while on duty. Additionally, a resident anonymously reported not being changed at night when requested, and another CNA stated that after one particular CNA worked, residents in that CNA’s care did not appear to have received appropriate care. These events collectively demonstrate failures to provide timely incontinence care, repositioning, and respectful, gentle personal care, resulting in neglect and, in one case, abusive rough perineal care that caused skin breakdown.
Failure to Keep Resident Call Lights Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights, a communication tool for requesting staff assistance, were kept within reach for all 10 sampled residents. Multiple observations showed call lights placed out of residents’ reach in various ways: hung over a headboard, clipped to the wall cord, lying near the floor, placed on bedside or overbed tables pushed away from the bed, or clipped to a recliner instead of near the resident in bed. One resident was observed slid down in bed and stated she did not know where her call light was and never had access to it. Another resident was in bed with the call light clipped to its own cord at the wall, and others were asleep or lying in bed with call lights positioned on tables or furniture not accessible from their positions. Interviews with staff confirmed awareness that call lights were expected to be within residents’ reach and that the observed placements were not appropriate. A resident who was calling out for help reported that no one would answer her call and that she needed to go to the bathroom; her call light was found at the foot of her bed despite signage indicating she was a high fall risk and that the call light should be attached to her at all times. CNAs, a CMA, an RN, an LPN, and the administrator each acknowledged that residents’ call lights were not within reach in the observed situations and stated that residents were supposed to have call lights accessible at all times, but the observations showed this was not consistently implemented.
Improper Non-Sterile Technique Used for Suprapubic Catheter Irrigation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s suprapubic catheter was irrigated using sterile technique and sterile equipment as required by the infection prevention and control program. Observation and interview with an LPN showed that the resident’s suprapubic catheter was flushed twice daily using a reused graduated cylinder that had been labeled "sterile only for vinegar and water, not to empty urine from the catheter," while only the syringe was changed each time. The LPN stated she had been trained to reuse the cylinder but could not recall who trained her. Review of the facility’s undated indwelling catheter irrigation policy indicated that prescribed irrigation solutions were to be used with a sterile basin and that commercially packaged kits containing sterile irrigation solutions, a graduated receptacle, and a catheter-tip syringe may be available. Further interviews revealed that the DON, who had recently started at the facility, understood that the container used for catheter irrigation should be changed every time and acknowledged that the resident had experienced urinary tract infections. A nurse manager training for the infection preventionist role reported she was not aware that non-sterile graduated cylinders were being used for the resident’s catheter flushes and confirmed that sterile urinary catheter kits were available and should have been used. Review of the resident’s EMR showed a physician’s order to flush the catheter with specific amounts of normal saline and 5% vinegar twice daily and as needed for a bladder disorder. The resident’s diagnoses included urinary retention, bladder disorder, overactive bladder, proteinuria, and bladder-neck obstruction, and her medications included cranberry capsules and methenamine hippurate for UTI prevention. The administrator stated that the LPN had been educated regarding the use of urine catheter kits and that nurses should know what a sterile field is.
Failure to Timely Assess, Document, and Treat Skin Injuries Resulting in Hospitalization
Penalty
Summary
The facility failed to provide quality care in the prevention and management of skin injuries for a resident with significant medical complexities, including chronic heart failure, peripheral vascular disease, malnutrition, and Brown-Sequard syndrome. The resident was dependent on staff for repositioning and transfers, and had a history of pressure ulcers, including an unstageable ulcer on the coccyx. Despite having a care plan and physician orders in place for regular skin assessments and wound care, staff did not consistently evaluate, document, or communicate changes in the resident's skin condition, particularly regarding new wounds on the left lower leg, left foot, and right lower leg. Multiple breakdowns in communication and documentation were identified. When new wounds were first observed, the responsible nurse did not complete a skin evaluation or document the findings, and there was confusion regarding the correct location of the wounds in communications with the physician. Treatment orders were delayed and not implemented promptly, and there were several days where no interventions were provided for the resident's leg wounds. Staff interviews revealed uncertainty about documentation procedures and a reliance on the wound care nurse to address new skin issues, rather than immediate action by the nurse who identified the problem. The lack of timely assessment, accurate documentation, and prompt intervention resulted in the resident's wounds worsening, ultimately requiring hospitalization. The facility's own policies required daily skin inspections, prompt reporting of changes, and immediate implementation of interventions for new or worsening wounds, but these procedures were not followed. The failures in evaluation, communication, and treatment placed the resident at risk for serious harm and led to the identification of an Immediate Jeopardy situation by surveyors.
Failure to Ensure Safe Mechanical Lift Transfers Due to Improper Sling Sizing and Lack of Assessment
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, a history of cervical spine fracture, and other complex medical conditions was transferred using a full-body mechanical lift and an incorrectly sized sling. During the transfer, the resident fell from the sling, striking her head on the floor and sustaining a hematoma behind her left ear. The staff involved, an LPN and a CMA/CNA, reported that all four sling straps were attached, but the sling slipped or became unhooked, resulting in the fall. The resident required hospital evaluation and imaging, which confirmed the hematoma but no acute fracture. The facility failed to ensure that sling sizes were properly assigned and used according to the manufacturer's instructions. Multiple brands and sizes of slings were in use, but staff relied on a single sizing chart (EZWay) for all brands, despite each manufacturer having different sizing criteria. For example, the Guldmann brand required three body measurements, not just weight, to determine the correct size, but these measurements were not performed. Observations and interviews revealed that staff were unaware of the differences in sizing guides and often selected slings based on availability or assumptions rather than proper assessment. Additionally, the facility lacked policies and procedures for assessing residents for mechanical lift use, determining appropriate sling size, and documenting this information in care plans. There was no clear assignment of responsibility for these assessments, and therapy staff did not evaluate residents for sling size. As a result, several residents were observed using slings of undetermined or potentially incorrect sizes, and staff could not confirm the appropriateness of the slings in use. The absence of standardized assessment and documentation contributed to the unsafe transfer and subsequent injury.
Failure to Implement Timely Pressure Ulcer Prevention and Intervention
Penalty
Summary
The facility failed to adequately identify and implement pressure ulcer prevention interventions for two residents who were at risk for developing pressure ulcers. One resident, who was non-ambulatory and had severe cognitive impairment, developed a pressure ulcer on her heel. Prior to the ulcer's identification, the resident had complained of heel pain, but heel protectors were not provided until after the skin breakdown was noted. Documentation showed that interventions such as heel boots and an air mattress were only added to the care plan after the ulcer developed. Additionally, there was no documentation that the resident’s representative was notified of the change in her condition, and the wound nurse included interventions in the clinical review that were not in place prior to the ulcer’s development. Another resident, who had a history of pressure ulcers and was at moderate risk according to the Braden Scale, developed a new pressure ulcer on her coccyx. Observations revealed that her heel boots were not in use as required, and she was often found lying on her back despite having a pressure ulcer in that area. The care plan indicated she needed a pressure-reducing mattress, but she was observed with a standard mattress. Staff interviews confirmed that repositioning was not performed as frequently as required, and documentation showed the resident was only repositioned one to three times per day, rather than every two to three hours as expected. The resident herself reported that staff did not reposition her and that she would have preferred more frequent repositioning. The facility’s own policy required timely risk assessments, implementation of individualized interventions, and prompt notification of changes in skin condition to the physician and resident representative. However, in both cases, interventions were either delayed or not implemented as planned, and documentation was incomplete or inaccurate. The clinical reviews to determine whether the ulcers were avoidable were not completed within the expected timeframe, and in one case, the review was left blank until after the deficiency was identified.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to residents' call lights, resulting in multiple instances where residents waited extended periods for assistance. Observations and interviews revealed that several residents experienced significant delays, with one resident reporting waits of up to two hours and another stating they had to wheel themselves into the hallway and call out for help. Call light audit data confirmed numerous occasions where response times exceeded 15 minutes, with some instances surpassing an hour. These delays were corroborated by both resident interviews and electronic call light system records. Residents affected by these delays included individuals with significant care needs, such as a quadriplegic resident requiring assistance for all mobility and transfers, and another resident with a history of falls and incontinence who reported wetting herself due to long waits. The call light system audit showed repeated 'needs improvement' flags for response times in multiple rooms. Residents expressed feelings of degradation, abandonment, and distress due to the lack of timely assistance, and some had documented pressure ulcers or other conditions that made prompt response critical. Staff interviews indicated that the expectation was for call lights to be answered within three to five minutes, but this standard was not consistently met, especially after meal times or when staffing was low. There was confusion among staff regarding who was responsible for answering call lights, and the facility lacked a formal policy on call light response. Resident council meeting minutes and grievance records further documented ongoing concerns about long call light response times and perceived short staffing, indicating a persistent issue affecting resident care and satisfaction.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications within the facility.
Deficient Food Service: Cold Meals, Inaccurate Menus, and Poor Communication
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature, as well as to provide accurate menus to residents. Multiple residents reported dissatisfaction with the quality, temperature, and organization of meal service. Several residents stated that their meals were often cold, particularly those who ate in their rooms or were served last in the dining room. Observations confirmed that meal trays were delivered on uninsulated carts and sometimes left in hallways before being distributed, contributing to food being served at suboptimal temperatures. A test tray delivered to surveyors showed food items below the recommended hot holding temperature, with potatoes at 132°F and pulled pork at 135°F, both described as cool to the touch and unappetizing. Residents also reported that menus were not consistently provided, making it difficult for them to know what meals would be served or to make alternate choices. Staff interviews confirmed that menu distribution had ceased since a new contracted food service company began operations, and residents now had to request menus from the dietary manager. Menu substitutions were frequent and often due to shortages or delivery issues, with documentation sometimes incomplete or missing. Residents expressed frustration with these changes, noting that the food served often did not match the posted or distributed menus, and that substitutions were not always communicated in advance. Resident council meeting minutes and grievance records further documented ongoing complaints about food quality, service delays, lack of condiments, and insufficient communication regarding meal options. Some residents were unaware they could request alternate meals or were not asked about their food preferences, despite care plans indicating the need to monitor intake and offer substitutes if necessary. The facility's own policies required food temperatures to be monitored and corrective action taken if standards were not met, but observations and records indicated these procedures were not consistently followed.
Failure to Follow Infection Prevention and Control Protocols
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices among staff members during resident care. Staff, including CNAs, LPNs, RNs, and housekeeping, were observed not performing proper hand hygiene, not using gloves and gowns as required, and contaminating clean supply fields during wound care. For example, during wound care for a resident with open wounds, staff failed to change gloves and perform hand hygiene between tasks, touched clean supplies with soiled gloves, and placed potentially contaminated items back into shared storage. Staff also failed to follow contact precaution protocols for residents with infectious conditions such as Clostridium difficile, including not wearing required personal protective equipment (PPE) and not performing hand hygiene before and after resident contact. Several residents with significant medical needs, such as those with stage IV pressure ulcers, C. difficile infections, and indwelling medical devices, were not provided care in accordance with established infection control policies. Staff did not consistently use gowns and gloves during high-contact care activities, such as transferring, dressing, and providing hygiene to residents on enhanced barrier precautions (EBP). In some cases, staff were unsure of the requirements for EBP or the location of necessary PPE, and there were instances where mechanical lifts were not sanitized between uses for different residents. The facility also failed to ensure that hand hygiene supplies, such as alcohol-based hand sanitizer (ABHS) and soap, were readily available and functional in resident rooms and bathrooms. Multiple rooms lacked ABHS dispensers or had dispensers that were empty or nonfunctional, and some rooms lacked soap. Housekeeping staff did not routinely check or refill these supplies, despite this being a stated responsibility. Facility policies required accessible hand hygiene products and outlined specific hand hygiene moments, but these were not consistently followed by staff during the survey period.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documentation showing that the investigation outcomes were shared with the appropriate external agencies. No additional details about the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Deficient Medicare Notice Practices and Incomplete Documentation
Penalty
Summary
The facility failed to provide proper Medicare notices to residents who were discharged from Medicare Part A skilled services and remained in the facility. For one resident, the Notice of Medicare Non-Coverage (NOMNC) form used was outdated and did not include the required non-discrimination clause. This was confirmed by the MDS/RN coordinator, who acknowledged the form was not current. For another resident, the NOMNC form was not signed or dated by the resident or their representative, as required by the form's instructions. Additionally, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for the same resident did not include a sufficient explanation in the "Reason Medicare May Not Pay" section, only stating "Custodial Care" without specifying the Medicare services being denied. There was also no documentation of who provided the verbal notification to the resident's representative. The MDS coordinator confirmed these omissions and was unable to identify who had given the verbal notice. Review of the relevant CMS form instructions confirmed that these elements were required for compliance.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The provider failed to update a resident's care plan to reflect his current needs regarding fall intervention after an incident where the resident fell from his wheelchair and sustained a head laceration. The resident, who had a history of dementia, diabetes, memory deficit, delirium, cerebral infarction, and psychosis disorder with hallucinations, was known to self-transfer and was forgetful. On the day of the incident, the resident attempted to self-transfer from his wheelchair, which had unlocked brakes, resulting in a fall that required hospital evaluation and stitches. Although a maintenance ticket was placed to add an anti-roll back bracket to the wheelchair, this intervention was not included in the resident's care plan. The director of nursing (DON) later discovered that the resident was sitting in the incorrect chair, and his wheelchair was found in another resident's room. The DON acknowledged that the intervention to add an anti-roll back bracket had been missed in the care plan update. The facility did not have a specific care plan policy to review, and the licensed nurse responsible for updating care plans failed to include the necessary intervention to prevent future falls. The facility's Fall Management and Neurological check policy required care plans to be updated after a fall, but this was not adhered to in this case.
Resident Falls Due to Inadequate Wheelchair Safety Measures
Penalty
Summary
A resident in a South Dakota nursing home experienced a fall resulting in a head laceration that required hospital treatment. The incident occurred when the resident attempted to self-transfer from a wheelchair that lacked an anti-roll back bracket, causing the wheelchair to roll backward. The resident, who had a history of dementia, memory deficits, and other cognitive impairments, was known to self-transfer and was forgetful. The facility's investigation revealed that the wheelchair brakes were not locked at the time of the fall, and a maintenance request had been made to add an anti-roll back bracket to the resident's wheelchair. Observations and interviews conducted after the incident showed that the resident was using a different wheelchair without the necessary anti-roll back bracket, indicating a failure to ensure the resident's safety as per the care plan. The care plan, which was supposed to include the anti-roll back bracket intervention, was not updated accordingly. The Director of Nursing acknowledged that the resident's wheelchair was found in another resident's room, and the intervention had been missed in the care plan update. The facility's fall management policy required care plans to be updated after falls, but this was not adequately followed in this case.
Failure to Provide Physician-Ordered Skin Care Resulting in Neglect
Penalty
Summary
A resident with a diagnosis of psoriasis was not provided with physician-ordered care for his lower extremities. The resident had orders for Aquaphor ointment to be applied to his legs every shift due to dry skin associated with psoriasis. Despite documentation in the electronic medical record indicating that this treatment was completed, interviews and assessments revealed that the care was not provided as ordered. The resident reported that the treatment had not been done for several days, and the nurse responsible admitted to not performing the care, despite documenting otherwise. Family members visiting the resident observed and reported significant care concerns, including a foul odor in the room, dirty and saturated socks, and the presence of maggots on the resident's feet. Photographic evidence provided by the family confirmed the presence of maggots and poor hygiene. Upon assessment by the DON and wound nurse, the resident's legs were found to be reddened, edematous, and covered with patches of dry skin, with socks saturated from leg drainage. There was no evidence that the ordered treatment had been provided prior to this assessment. Further investigation revealed that the nurse had used vinegar to wash the resident's legs, which was not part of the physician's orders. The use of vinegar was only discontinued after a new physician's order was obtained in response to family concerns. The facility's policy defines neglect as the failure to provide necessary goods or services to avoid physical harm, pain, or emotional distress, and the actions and inactions of the staff in this case met that definition.
Care Plan Failed to Reflect Physician-Ordered Skin Treatments
Penalty
Summary
The facility failed to ensure that the care plan accurately reflected the current individualized care needs for a resident with physician-ordered skin treatments. The resident had multiple diagnoses, including psoriasis, vascular dementia, diabetes, peripheral vascular disease, chronic kidney disease, bipolar disorder, and localized edema, and was cognitively intact. Physician orders were in place for daily skin care to the lower extremities, including specific instructions for washing, drying, applying ointments, and using dressings and compression wraps. These orders were updated as treatments changed, such as discontinuing Aquaphor and starting Vaseline. Weekly skin observations were documented, and behavior charting noted refusals of care. Despite these detailed physician orders and ongoing assessments, the resident's care plan did not include the updated or specific interventions ordered by the physician, such as the daily dressing changes and use of compression wraps. The care plan only referenced general skin care interventions like barrier cream, lotion, and pressure-relieving devices, and did not reflect the physician's orders from 10/31/24 or subsequent changes. Interviews with facility staff revealed there was no formal care plan policy, and updates to care plans were made by the DON or RCM/LPN as needed, but the required changes for this resident's skin care were not incorporated into the care plan.
Medication Administration Error with Sevelamer
Penalty
Summary
The provider failed to ensure that a certified medication aide (CMA) administered medication according to pharmacy directions for a resident with end-stage renal disease and other disorders of phosphorus metabolism. The resident was prescribed Sevelamer HCL to control high phosphorus levels due to his dependence on dialysis. Despite a physician's order to crush all medications in applesauce, the CMA crushed Sevelamer, which had a label indicating it should not be crushed. The CMA removed the coating from the crushed tablets and mixed the remaining powder with applesauce, but did not ensure the resident swallowed the medication before leaving the room. The facility had a standing order to crush medications in applesauce, but no audits were conducted to ensure compliance with medication administration. The director of nursing (DON) was unaware that Sevelamer was being crushed, which was considered a significant medication error. The facility's policy stated that medications should be administered as prescribed and in accordance with manufacturer's specifications, and that personnel should familiarize themselves with the medication before administration. The policy also emphasized that medications with labels indicating they should not be crushed should not be altered, and residents should be observed to ensure the medication is ingested.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
