Riverview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Flandreau, South Dakota.
- Location
- 611 East 2nd Ave, Flandreau, South Dakota 57028
- CMS Provider Number
- 435086
- Inspections on file
- 24
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Riverview Healthcare Center during CMS and state inspections, most recent first.
Two residents who required two-person assistance with mechanical lifts were subjected to unsafe transfers when CNAs used improperly sized, mispositioned, or incompatible full-body slings and did not follow manufacturer instructions. In one case, a resident newly admitted with a hospital-provided sling was lowered to the floor during a lift transfer after sliding forward in the sling, resulting in reported rib pain but no fractures on X-ray. In another case, a resident’s wheelchair pad and handle became entangled in a large sling during a lift, causing the wheelchair and resident to be lifted off the floor; the sling remained incorrectly positioned at mid-back when the resident was lifted again and moved to bed. Multiple CNAs and nurses reported no recent facility-specific training or competencies on mechanical or sit-to-stand lifts, selected sling sizes by guessing based on body type or using whatever sling was in the room, and lacked clear, updated care plan or Kardex documentation specifying lift type and sling size for residents who required mechanical lifts.
A resident with moderately impaired cognition, Parkinson’s disease, dementia, high fall risk, and moderate pressure-ulcer risk, who required a sit-to-stand lift and maximal assistance for toileting and hygiene, was taken to a beauty shop bathroom by a CMA and left unattended with the lift attached, the door closed, and no call light activated. The resident was later found by a nurse after an extended, unknown period and had transient redness on the buttocks consistent with prolonged sitting. Documentation lacked a post-incident pain and skin assessment. Staff interviews showed there was no clear, consistent process for how often CNAs should check on residents left on toilets, and an observation revealed a staff member failed to change the beauty shop door sign to indicate occupancy, all occurring under a facility neglect policy that defines neglect as failure to provide necessary goods and services to avoid harm.
The facility failed to timely submit initial and final FRI reports to the SD DOH for multiple residents who experienced alleged abuse, falls with injury, seizures, head lacerations, and fractures. In several cases, initial reports were submitted many hours or days after serious events, exceeding the required 2‑hour or 24‑hour timeframes, and in numerous instances no final investigation report was ever submitted within the required 5 working days, despite state complaint records and rejections requesting completion. The administrator and DON, who were responsible for reporting and aware of the regulatory timeframes, acknowledged ongoing issues with incident reporting, while the facility’s own abuse reporting policy required immediate reporting of suspected abuse and timely submission of investigation results.
Two residents with significant symptoms did not receive timely completion of ordered diagnostic tests. For one resident with cirrhosis and acute kidney failure who reported painful urination, fever, and urinary urgency, a physician ordered a same‑day UA, but facility staff did not collect the sample as ordered; the resident was later evaluated at a clinic, found to have urinary retention, had a Foley catheter placed, and was treated for suspected UTI. For another resident with intracerebral hemorrhage who had dark black stools and strong‑smelling urine, the physician ordered CBC, CMP, and UA on the same day staff reported these symptoms, but the order was not acknowledged for several days, the CBC result was not available, the CMP had to be recollected, and the UA was delayed and ultimately not obtained after the physician later indicated it was unnecessary without additional symptoms. Staff and the DON acknowledged that physician orders were expected to be processed immediately and that these labs and UA should have been collected on the day the orders were received.
A cognitively intact resident reported that a CNA verbally and physically abused him during evening care, stating he was slapped, pushed onto the bed, and choked. The resident disclosed the alleged abuse to a CNA during a bath, who then informed the SSD, and the concern was brought to the IDT, but the administrator did not promptly follow up that same day. The resident repeated the allegation to an LPN/CC and later to a counselor, while assessments showed no visible injuries. Despite a written abuse policy requiring that all abuse allegations be reported to the state survey agency within 2 hours, the facility did not ensure that this allegation was reported within the required timeframe, resulting in a reporting deficiency.
A resident with significant medical needs and high risk for pressure ulcers developed untreated blisters that progressed to a stage 2 pressure ulcer after staff failed to implement wound care orders, document assessments, or communicate with the wound nurse and primary care provider, resulting in a lack of timely intervention.
A CNA did not secure a safety belt on a whirlpool bath chair while bathing a resident who was totally dependent on staff for transfers and mobility, resulting in the resident sliding out of the chair and falling to the floor. The resident had multiple complex medical conditions and required two-person assistance, but the use of the safety belt was not standard practice at the time. Staff interviews and observations confirmed that the safety belt was available but not routinely used prior to the incident.
Staff failed to protect residents from abuse and neglect, including a CNA responding rudely and aggressively to a resident's pain medication request, a CMA refusing to assist a resident with medication leading to emotional distress, and another CNA escalating a situation with a cognitively impaired resident by acting aggressively and physically taking food from the resident.
A resident with cancer, acute kidney failure, and anxiety experienced worsening abdominal pain and swelling, repeatedly reporting inadequate pain control and requesting to see a specialist. Despite frequent administration of PRN oxycodone, acetaminophen, and lorazepam, staff did not document provider consultation or schedule the required follow-up after an emergency department visit, resulting in ineffective pain management and lack of timely medical intervention.
Two residents did not receive critical physician-ordered medications—one missed multiple doses of anti-seizure medication, resulting in increased seizure activity and ED transfer, while another missed a week of blood thinner due to a lab schedule change and lack of pharmacy notification. Staff interviews revealed inconsistent medication reordering practices, and the facility's policy to reorder with a three-day supply remaining was not consistently followed.
Two residents with cognitive impairment and mobility needs were able to leave the facility without staff knowledge due to failures in supervision, improper use of WanderGuard devices, and lack of enforcement of sign-out procedures. One resident exited through an unalarmed patio door and walked to a bar, while another left through the main entrance when the WanderGuard was incorrectly placed, preventing the alarm from sounding. Staff did not consistently follow or enforce elopement prevention policies, leading to both residents being outside the facility unsupervised.
A facility failed to provide quality care by improperly delegating wound care from an RN to a CNA, leading to inadequate treatment for a resident. Additionally, two residents experienced poor hospice care coordination, resulting in unassessed pressure ulcers and unmanaged pain. The DON was unaware of these issues, highlighting a lack of communication and adherence to care protocols.
The facility failed to prevent and manage pressure ulcers for three high-risk residents. A resident developed stage two pressure ulcers on both heels and an abrasion on the coccyx due to inadequate repositioning. Another resident on hospice care developed a Kennedy ulcer and a thigh injury, with insufficient documentation and communication with the primary care physician. A third resident, severely cognitively impaired, developed stage two pressure ulcers on the coccyx and buttocks due to infrequent repositioning. The DON acknowledged these were preventable and highlighted concerns about staff training.
A hospice resident experienced unmanaged pain during repositioning, with staff documenting zero pain despite visible discomfort. The resident's care plan and physician's orders for pain management were not effectively followed, leading to inadequate pain control.
The facility failed to maintain food safety standards, with unsanitary kitchen conditions, improper food storage, and inadequate hand hygiene during meal service. Observations revealed mold in the cooler, expired food, and incomplete temperature monitoring. Staff did not follow glove use protocols, contributing to the deficiencies.
The facility failed to maintain a homelike environment, with significant damages observed in various areas, including a shared bathroom with exposed chicken-wire ceiling, a rusted emergency exit door frame, and missing flooring in the therapy gym. Staff were aware of some issues but faced delays in addressing them due to contractor scheduling difficulties.
A long-term care facility was found deficient in infection control practices, with an RN and CNAs failing to follow proper hand hygiene and wound care protocols. The RN did not use barriers under wound care supplies and failed to perform hand hygiene between glove changes. CNAs did not sanitize hands before donning PPE and used the same towels for different body parts, risking cross-contamination. The facility's environment, including the whirlpool tub and therapy gym, was not maintained in a cleanable condition, contributing to the deficiencies.
A resident with stage II pressure ulcers on both heels and an abrasion on the coccyx did not have an updated care plan reflecting these conditions. The care plan, last revised months earlier, failed to include the current skin impairments, contrary to the facility's policy. The DON acknowledged the care plan did not meet the resident's current needs.
The facility failed to address deficiencies in pressure ulcer prevention, infection control, and pain management. The medical director was unaware of the lack of a repositioning policy, and the DON acknowledged the need for improvement in infection control and wound care. The QAPI plan did not adequately address these critical areas, and there were environmental issues such as missing ceiling tiles and dirty equipment.
The provider failed to maintain the walk-in cooler and freezer according to industry standards. The cooler door did not seal properly, allowing light and creating a gap, while mold-like growth was observed on various surfaces. The freezer had ice buildup due to improper temperature control, with a condenser panel hanging unsecured and blowing hot air. The dietary manager was aware of these issues.
Two residents with dementia were subjected to physical and verbal abuse by a CNA, including being kicked and having a washcloth placed over the mouth. Despite reports from staff, the facility failed to protect the residents, conduct a thorough investigation, or report the incidents promptly. The DON and ED were aware of the allegations but did not follow the facility's abuse prevention policies.
The provider failed to report and investigate allegations of abuse by a CNA towards two residents. The CNA continued working after the allegations were known, and the initial report to the DOH was delayed. Witnesses indicated a history of abusive behavior by the CNA. The DON and ED were aware of the allegations but did not report them to the required entities.
The provider failed to investigate and report allegations of abuse by a CNA towards two residents with dementia. Despite being aware of the allegations, the provider allowed the CNA to continue working, did not report the incidents promptly, and conducted an inadequate investigation. The DON was unaware of the abuse policy, and the investigation lacked documentation and thoroughness.
The facility's administration failed to ensure resident safety and well-being due to inadequate management by the ED and DON. They did not maintain an effective abuse prohibition program, failing to report and investigate abuse allegations by a CNA towards two residents. Additionally, residents' privacy was compromised by a staff member secretly recording conversations. The DON allowed the implicated CNA to continue working, and the ED was aware of the situation but did not take appropriate action.
A staff member at an LTC facility secretly recorded private conversations of three residents to gather evidence of alleged abuse by a CNA. The recordings were shared with the executive director, who initially denied knowledge of the allegations. The facility's policies prohibit unauthorized recordings, and the staff member was suspended pending investigation for violating HIPAA and company policies.
A resident with dementia and a history of exit-seeking behavior eloped from the facility despite having a functioning Wanderguard. The resident was found a half mile away and returned by staff. The facility failed to conduct a thorough investigation into the incident, and staff misinterpreted the alarm triggered by the resident's exit. The Director of Nursing acknowledged the need for a more comprehensive investigation.
Improper Mechanical Lift Use and Inadequate Sling Selection for Dependent Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of total body mechanical lifts and appropriate slings for residents requiring two-person assistance for transfers. Contracted travel CNAs and facility CNAs used incompatible or improperly sized and positioned slings, and staff lacked clear, accessible information on which sling size and type to use for specific residents. Surveyors identified that staff often selected sling sizes based on visual estimation of body size or by using whatever sling was present in the room, rather than following resident-specific guidance. Care plans and Kardexes for multiple residents who required mechanical lifts did not specify the type of lift (full body or sit-to-stand) or the correct sling size, leaving staff without written direction. One incident involved a resident who had been admitted earlier that day with a full body lift sling brought from the hospital. During a transfer from wheelchair to bed using a full body lift, two CNAs attached the sling provided by the family and began the transfer. As one CNA attached the lower body sling straps to the lift hooks, the resident moved and slid forward in the sling. The CNAs readjusted the resident and completed attaching the sling, but the resident continued to move and slid toward the edge of the wheelchair seat, causing the sling to tilt downward. Unable to safely complete the transfer, the CNAs lowered the resident to the floor using the upper portion of the sling while the lower portion remained attached to the lift. The resident’s buttocks contacted the floor first, she was then assisted to a lying position, and she reported rib pain; a subsequent chest X-ray showed no breaks or fractures. This event was identified as the start of Immediate Jeopardy at F689. Another observed incident involved a different resident being transferred from a wheelchair to a bed using a full body lift and a burgundy (large) sling. Two contracted travel CNAs placed the sling behind the resident, pulled the lower straps under her thighs, and interlaced the straps. As they began lifting, the resident’s wheelchair pad and the left handle of the wheelchair became caught in the sling, causing the wheelchair to lift off the floor with the resident still seated. While the resident and wheelchair were suspended, one CNA pulled on the wheelchair pad to free it, and the CNAs switched tasks while the resident remained in the air. After lowering the resident and wheelchair back to the floor and freeing the wheelchair handle, they did not reposition the sling, which was noted to be placed too high, with the bottom of the sling at the resident’s mid-back instead of under her buttocks. They then lifted the resident again and transferred her to the bed, with one CNA stating during the lift that the setup was “all wrong.” Interviews with multiple CNAs and nursing staff revealed that many had not received recent or any facility-specific training or competencies on safe use of mechanical lifts and sit-to-stand lifts. Several CNAs reported choosing sling sizes based on the resident’s body type or guessing, and one CNA stated she relied on training from previous employers. Staff were generally unaware of which sling to use for specific residents and could not readily locate up-to-date written resources; binders that were supposed to contain lift and sling information were missing or outdated. A paper list of sling sizes found in a communication binder was acknowledged by an RN as not updated. Another RN stated she did not know residents’ sling sizes and would ask a CNA for guidance. Record review confirmed that not all direct care staff, including CNAs involved in the incidents, had completed required competencies on total body lifts or sit-to-stand lifts after the reported incident, despite having worked shifts since that time. Further review of resident records showed that for several residents who used mechanical lifts, care plans and Kardexes lacked documentation of sling size and, in some cases, did not even specify the type of lift to be used. For example, one resident’s care plan and Kardex indicated a need for two-person assistance with transfers but did not identify any transfer equipment. Surveyors also compared an updated list of transfer equipment to slings stored in residents’ rooms and found discrepancies between listed sling sizes and those actually present or documented in the Kardex for certain residents. The facility’s own sling sizing chart and manufacturer’s instructions for the EZ Way Smart Lift outlined proper sling positioning and sizing parameters, including that the base of the sling should be positioned two inches below the tailbone and the top parallel with the shoulder line, but observed practice and staff statements demonstrated that these guidelines were not consistently followed.
Resident Left Unattended on Toilet Resulting in Potential Neglect
Penalty
Summary
The deficiency involves a resident being left unattended on a toilet in the beauty shop bathroom for an extended period, despite requiring staff assistance and supervision. The resident was later found by the charge nurse sitting on the toilet with the sit-to-stand lift still attached, the bathroom door closed, and the call light not activated. Prior to this, a CNA had noticed the resident’s room call light on, but the resident was not in his room; the CNA turned off the call light and proceeded to answer other call lights without locating the resident. The facility’s investigation identified that a certified medication aide (CMA) had taken the resident to the beauty shop bathroom earlier in the afternoon but did not inform other staff or acknowledge doing so, even though witnesses reported seeing the CMA escort the resident to that bathroom. The resident’s medical record showed moderately impaired cognition with a BIMS score of 8, diagnoses including Parkinson’s disease, unspecified dementia, hallucinations, and sensorineural hearing loss, and a high fall risk with a Morse fall scale score of 75. The care plan documented the need for a sit-to-stand lift for transfers, maximal/substantial assistance for toileting, and dependence on staff for toileting hygiene, as well as a focus on risk for pressure ulcer development related to immobility and incontinence. A Braden scale score of 13 indicated moderate risk for pressure ulcers. After being left on the toilet for an unknown but extended time, the resident was assessed by the charge nurse and found to have slight redness on the buttocks consistent with prolonged sitting on the toilet seat; the redness resolved before the end of the shift. There was no documented pain assessment or skin assessment in the medical record following this incident. Staff interviews revealed inconsistent practices and lack of clear guidance regarding monitoring residents left on toilets. One CNA reported checking assigned residents every two hours and returning to the bathroom within five to ten minutes if a resident did not use the call light, noting that longer periods on the toilet could cause redness from pressure. Another CNA stated that some resident bathrooms were too small for lift equipment, so residents were taken to the beauty shop bathroom, but there was no specific process or policy on when staff should return to assist residents off the toilet; she relied on remembering to go back. During observation, a staff member transferred a resident into the beauty shop and closed the door without changing the door sign from “Vacant” to “Occupied.” The facility’s neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and outlined procedures for investigation and protection of residents, but there was no documentation that audits were conducted to ensure staff understood and implemented resident safety interventions related to this incident.
Failure to Timely Report Facility Incidents and Investigation Results to SD DOH
Penalty
Summary
The deficiency involves the facility’s failure to timely submit initial and final Facility Reported Incident (FRI) reports to the South Dakota Department of Health (SD DOH) for multiple residents who experienced reportable events, including alleged abuse, falls with injury, and other serious incidents. For one resident who reported an allegation of abuse on 1/3/26 at 6:00 p.m., the initial report was not submitted until 1/14/26 at 9:45 a.m., approximately 11 days after the event, and the final investigation report was submitted on 1/16/25, outside the required time frames. The SD DOH complaint record stated the facility failed to ensure timely reporting for this resident and that the delay failed to ensure immediate protection and oversight. The administrator acknowledged awareness of the required reporting time frames and responsibility for reporting but could not identify why the reports were not completed on time. The facility also failed to meet reporting requirements for several residents who had falls requiring further medical evaluation. One resident had a fall with a head laceration requiring staples on 12/28/25 at 9:45 p.m.; the initial report was not submitted until 12/29/25 at 8:37 p.m., exceeding the 2‑hour requirement, and the final report was not received until 1/20/26, beyond the 5 working‑day requirement. The SD DOH complaint record stated this failure placed the resident at risk for unaddressed abuse or neglect. The same resident had another fall with a head laceration on 1/4/26 at 2:28 p.m.; while the initial report was timely at 3:29 p.m., no final investigation report was ever submitted. Another resident had a fall on 10/13/25 at 4:18 p.m. with head and pelvic pain; the initial report was timely, but the SD DOH rejected the report twice requesting a final investigation, and no final report was submitted. The DON stated the final investigation report “got stuck in the cracks.” Additional residents experienced falls with injuries or serious symptoms for which the facility did not meet initial or final reporting requirements. One resident had a fall with a head laceration on 11/5/25 at 8:55 p.m.; the initial report was not submitted until 1:41 p.m. the next day, exceeding the 2‑hour requirement, and no final report was submitted despite SD DOH rejections and requests. Another resident had a fall with a seizure on 11/16/25 at 7:30 p.m.; the initial report was not received until 7:11 p.m. the following day, and no final investigation report was submitted. A different resident had a fall with head impact and seizure on 12/5/25 at 9:05 p.m.; the initial report was submitted the next day at 12:12 p.m., and the final report on 12/15/25, both beyond required time frames. One resident sustained a left arm fracture from a fall on 12/17/25 at 5:30 a.m.; the initial report was not received until 12/29/25 at 9:29 p.m., and no final report was submitted, with documentation showing inconsistent event dates. Another resident was involved in alleged potential resident‑to‑resident physical abuse on 11/21/25 at 7:00 a.m.; the initial report met the 24‑hour requirement, but no final investigation report was submitted. Interviews with the administrator and DON confirmed that they were responsible for completing initial and final FRI reports to the SD DOH and that they were aware of the state’s required time frames: allegations, falls of unknown origin, and falls with major injury to be reported within 2 hours, and all other incidents within 24 hours, with final investigation reports due within 5 working days. The administrator acknowledged the facility had issues with reporting FRIs and stated that staff were to call her or the DON at any time to inform them of incidents so they could determine reportability. She reported that all managers had completed education on reportable incidents, and about half of all staff had completed related education by the time of the survey. The facility’s Abuse Reporting and Response policy required immediate reporting of suspected or alleged abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source, and mandated reporting of investigation results to the state survey agency within 5 working days, but the documented events and complaint records showed repeated failures to follow these requirements for nine residents.
Failure to Timely Complete Ordered UA and Lab Work for Two Symptomatic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and complete ordered diagnostic tests for two residents with concerning symptoms. For one resident with alcoholic cirrhosis, ascites, and acute kidney failure, the physician issued an order on 1/12/26 at 2:57 p.m. to collect a urine analysis (UA) sample and bring it to the clinic that day. Nursing documentation later that afternoon recorded the resident’s complaints of painful urination with sharp pain on attempting to void, increased frequency and urgency, a temperature of 101.1°F, pulse of 103, and pain rated 10/10. Despite these symptoms and the explicit same‑day order for a UA, the urine sample was not collected by facility staff on 1/12/26. On the following day, staff documented that the resident’s temperature had increased to 102°F and that the primary care provider requested the resident be seen at the clinic that day and to postpone scheduled GI testing. A late entry note indicated the provider, during in‑house rounds, recommended the resident be seen in the clinic due to fever and nausea. At the clinic, a bladder scan showed 906 cc of retained urine, a Foley catheter was inserted, a urine sample was obtained, IV antibiotics were administered, and oral antibiotics were ordered for a suspected UTI. The DON later confirmed there was no documentation of what information had been sent to the physician before the UA order on 1/12/26 and acknowledged that the UA should have been collected that day as ordered, and that not doing so may have caused a delay in treatment. LPN/CC F also stated the UA should have been collected on 1/12/26. The second resident had a diagnosis of intracerebral hemorrhage and a BIMS score indicating moderately intact cognition. Staff faxed the physician reporting dark black stools for two days and strong‑smelling urine. The physician responded with an order for CBC, CMP, and UA to be done that day, noting the resident was on iron, which could cause dark stools versus GI bleed. The order, faxed on 1/9/26, was not acknowledged in the record until 1/13/26. During this period, the physician emailed on 1/9/26 requesting a status update; LPN/CC F replied that the resident’s vital signs were stable, the resident felt fine, and staff had no further information. LPN/CC F later confirmed that the attached document to the physician’s email was the lab order and that the labs, including UA, should have been collected on 1/9/26 when the order was received. On 1/13/26, a progress note documented that the CNP had ordered CBC, CMP, and UA to be collected that day. LPN/CC F reported collecting the CBC and CMP at 11:31 a.m., but the CMP had to be recollected by the lab the next morning because the initial sample could not be tested. A subsequent note indicated that the day and evening shifts did not obtain a urine sample and that the resident was asleep, so the UA collection was rescheduled. On 1/14/26, the CMP was collected at 8:15 a.m., and LPN/CC F emailed the physician to review the labs; the physician replied that the labs were okay and later stated a UA was not needed unless the resident had symptoms other than odor. There was no CBC report available for review, and documentation showed the CMP was obtained by the clinic. The DON stated she was unsure when the lab order was received but expected labs to be collected the day the order was received if during lab hours. Staff interviews confirmed that physician orders were to be processed immediately and entered into the EMR the same shift they were received, and that resident 5’s labs, including UA, should have been collected on 1/9/26 when the order was received.
Failure to Timely Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required time frame after a cognitively intact resident reported being physically abused by a CNA. The resident, who had a BIMS score of 15 indicating intact cognition, alleged that on the evening of 1/3/26 a CNA verbally assaulted him, slapped him, pushed him into bed, and choked him during provision of care. A scheduled skin assessment on 1/5/26 documented no bruising or finger marks, and later assessment found no signs or symptoms of injury. The resident’s care plan noted a history of making accusatory statements about non-Caucasian staff and a preference for Caucasian staff, with a statement that all such reports would be taken seriously and investigated per policy. On the morning of 1/5/26, during the resident’s bath, he told a CNA that he had been physically abused by the CNA involved on 1/3/26. That CNA reported the allegation to the social services director the same morning. The social services director then reported the allegation to the interdisciplinary team meeting held that day and indicated that, after her report, the matter was to be handled by the administrator. Despite this, the administrator later acknowledged that she did not follow up with the resident on 1/5/26 when the allegation was reported, but instead waited until 1/6/26 to do so. Additional interviews further documented the resident’s repeated reports of the alleged abuse. On 1/8/26, while being checked on by an LPN/care coordinator, the resident again stated that over the weekend a “black lady” CNA had pushed him down on his bed while assisting with care. On 1/9/26, during an in-person interview with a counselor, the resident reported that the CNA became physical with him during his evening cares on 1/3/26, while also stating he had a sense of safety in the care setting and denied feeling intimidated by others. The facility’s abuse policy required that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported to the state survey agency immediately but not later than 2 hours, based on real clock time. The failure to ensure that this resident’s abuse allegation was reported to the state within the required time frame constituted the cited deficiency.
Failure to Implement Wound Treatment Orders and Prevent Pressure Ulcer Development
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, dysphagia, diabetes with neuropathy, and aphasia, was admitted to the facility and identified as being at high risk for developing pressure ulcers based on Braden Scale assessments. The resident was nonverbal, required total assistance for all activities of daily living, and was unable to reposition herself in bed. Initial skin assessments upon admission showed intact skin, but subsequent documentation was lacking until after a hospitalization. On one occasion, a registered nurse documented the presence of two blisters on the resident's buttocks and notified a telemedicine provider (eCare), who gave orders for wound care, including the application of Opti Foam dressings and continued repositioning. However, there was no evidence that these orders were entered into the electronic medical record, implemented, or communicated to the wound nurse, primary care provider, or the resident's representative. There was also no documentation of a skin assessment of the blisters, nor was there evidence of regular repositioning or monitoring as required by the resident's care plan and facility policy. The only documentation related to the blisters was a progress note and a scanned eCare note, neither of which were signed or acknowledged by nursing staff. Interviews with staff revealed confusion and lack of recall regarding the wound care orders and the resident's condition. The facility's skin integrity policy required systematic assessment, documentation, notification, and intervention for skin impairments, but these steps were not followed. As a result, the blisters went untreated for several days, and the resident developed a stage 2 pressure ulcer on her sacrum, which was identified during a subsequent hospital admission. There was no evidence that the required notifications, assessments, or interventions were completed in accordance with facility policy.
Failure to Use Bath Chair Safety Belt Results in Resident Fall
Penalty
Summary
A certified nursing assistant (CNA) failed to use the safety belt on a whirlpool bath chair while bathing a resident who was totally dependent on staff for transfers and mobility. The resident, who had been admitted the previous day, was assisted into the bath chair using a full-body mechanical lift by two CNAs. After the bath, while the resident was still seated in the bath chair, the CNA wheeled the resident away from the tub without securing the safety belt, resulting in the resident sliding out of the chair and falling to the floor. The resident involved had multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, restlessness, agitation, dysphagia, major depressive disorder, gastrostomy status, encephalopathy, Type 2 diabetes mellitus with neuropathy, aphagia, and acute respiratory failure with hypoxia. The resident was nonverbal at baseline and required total assistance for transfers and bed mobility, as documented in her care plan. At the time of the incident, the care plan specified two-person assistance for transfers but did not yet include specific interventions for bathing safety or the use of the bath chair safety belt. Interviews and observations revealed that, prior to the incident, it was not standard practice or policy at the facility to use the bath chair safety belt for all residents. The CNA involved in the incident was relatively new and did not secure the safety belt during the bath. Other staff confirmed that the use of the safety belt was not routinely enforced before the fall occurred. The safety belt was available and present in the whirlpool bath rooms, but its use was not consistently implemented.
Failure to Protect Residents from Abuse and Neglect by Staff
Penalty
Summary
Multiple incidents occurred in which staff failed to protect residents from abuse and neglect. In one case, a certified nursing assistant (CNA) responded to a resident's request for pain medication in a rude and unpleasant manner, telling the resident she would receive her medication only when her name came up on the nurse's list. When the resident repeated her request, the CNA responded with an unpleasant tone, reiterated her previous statement, and slapped her fist on the door. The resident reported feeling distressed and anxious as a result of this interaction, and subsequently avoided using her call light and experienced increased anxiety when seeing the CNA. In another incident, a certified medication aide (CMA) refused to assist a resident with taking her medication. The resident, who had a history of schizoaffective disorder, trauma, bipolar disorder, and anxiety, requested help with her cup of water while taking her medications. The CMA was reportedly rude and did not want to help with small tasks. After the incident, medication pills and water were found on the floor of the resident's room, and the resident was observed crying and expressing emotional distress. The resident's care plan indicated she required assistance with nutritional needs if her hands were not working properly, but did not specify that staff must remain with her during medication administration. A third incident involved a CNA who, in a joking manner, told a resident he would fight him for a breakfast bar the resident had taken from a snack cart. The CNA's actions escalated, becoming aggressive as he approached the resident in a boxing stance, circled the resident's wheelchair, grabbed the resident's arm, and took the breakfast bar from his hand. The resident, who had severe cognitive impairment, cerebral palsy, and communication difficulties, was assessed and found to have no injuries, but the interaction was verified as inappropriate and aggressive by witnesses.
Failure to Provide Effective Pain Management and Timely Follow-Up
Penalty
Summary
A resident with a history of secondary malignant neoplasm of digestive organs, acute kidney failure, and anxiety disorder experienced increasing abdominal pain and swelling over several days. Despite repeated complaints of pain, visible abdominal swelling, and inability to reposition due to discomfort, the resident reported that her pain was not being adequately controlled and felt that nothing was being done to address her concerns. The resident expressed a desire to see her specialist, and her pain was frequently rated at 6/10, escalating to 10/10 on the day of transfer to the emergency department. Review of the resident's electronic medical record showed multiple administrations of PRN oxycodone and acetaminophen for pain, as well as lorazepam for anxiety. The resident was sent to the emergency department for evaluation of increased abdominal pain, where she received additional pain and anxiety medications. Upon return to the facility, discharge instructions included a follow-up appointment with her primary care physician within two to four days; however, there was no documentation that this follow-up was scheduled or completed, nor was there evidence of follow-up care after the emergency department visit. Progress notes and staff interviews indicated ongoing concerns about the resident's pain, with staff documenting frequent requests for pain medication and persistent high pain ratings. Despite these reports and visible symptoms, there was a lack of documented provider consultation or escalation of care in response to uncontrolled pain, as required by the facility's pain management policy. The deficiency was identified due to the failure to provide effective and appropriate pain management and to ensure timely follow-up and provider involvement for a resident with significant pain and complex medical needs.
Failure to Ensure Timely Medication Administration Due to Inadequate Reordering Practices
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for two residents, resulting in significant medication errors. One resident did not receive five doses of a physician-ordered anti-seizure medication, Zonisamide, due to the medication being on order from the pharmacy and not available for administration. This resident subsequently experienced increased seizure activity, including seizures lasting longer than five minutes, which led to a transfer to the emergency department. Documentation and interviews revealed inconsistent practices among staff regarding when to reorder medications, with some staff waiting until the last dose was administered and others reordering with several doses remaining. The pharmacy was not notified in a timely manner, and the facility's policy required medications to be reordered in advance, with a three-day minimum supply remaining. Another resident did not receive a physician-ordered blood clot prevention medication, Coumadin, for seven days. The missed doses were attributed to a change in the resident's lab schedule, which affected the pharmacy's ability to adjust and supply the medication. The pharmacy was not notified of the updated schedule, resulting in the medication not being reordered or administered during this period. The resident's electronic medical record confirmed the absence of Coumadin administration for the specified days. Interviews with nursing staff and the pharmacy director highlighted a lack of consistent understanding and adherence to medication reordering procedures. Staff reported varying practices for reordering medications, and the pharmacy director noted that medication requests sent by fax on weekends or holidays were not checked, despite the availability of a phone number for urgent orders. The facility's policy and medication reorder sheets instructed staff to reorder medications in advance to prevent missed doses, but these procedures were not consistently followed, leading to the deficiencies identified.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lapses in Safety Procedures
Penalty
Summary
Staff failed to implement adequate interventions and supervision to prevent two residents from eloping without staff knowledge. In the first incident, a resident with a history of left femur fracture, alcohol abuse, tobacco use, and moderately impaired cognition (BIMS score of 12) was able to exit the facility through a patio door that was neither alarmed nor locked at the time. The resident, who required partial to moderate assistance for mobility and used a wheelchair and walker, left his wheelchair on the patio and walked unassisted to a nearby bar to purchase cigarettes. Staff only became aware of his absence after noticing his wheelchair was left unattended, prompting a search and eventual retrieval of the resident from the community. The resident was not wearing a WanderGuard device, and the patio door's alarm system was not in place at the time of the incident. The sign-out procedure was not followed, as the resident did not sign out or notify staff before leaving. In the second incident, another resident with epilepsy, mild cognitive impairment, Alpers Disease, and a history of wandering was found outside the facility without staff knowledge. This resident had a WanderGuard device, but it was placed on the right ankle instead of the left, which prevented the door alarm from activating when the resident exited through the main entrance. The resident was able to move independently in a wheelchair and stated he wanted to go outside to talk to another resident. Staff discovered the resident outside after being alerted by another staff member who saw him from a window. The door alarm system and WanderGuard device were later tested and found to be functional when used as intended, but the improper placement of the device allowed the resident to exit undetected. Documentation showed that elopement risk assessments and care plan updates were not consistently completed or updated in response to changes in the resident's condition and behavior. Interviews with staff and review of facility policies revealed that the sign-out and supervision procedures were not consistently enforced. Residents assessed as safe to leave independently were expected to sign out, while others required staff or family supervision. However, in both incidents, the residents exited without proper notification or supervision, and the required safety devices and procedures were either not in place or not correctly implemented. The facility's elopement/wandering policy defined elopement as any resident exiting the center without staff knowledge, but the policy was not effectively followed in these cases.
Improper Delegation and Inadequate Care Coordination
Penalty
Summary
The provider failed to ensure quality care for a resident whose wound care was improperly delegated by an RN to a CNA. The resident, who was cognitively intact, had a physician's order for specific wound care involving the application of moistened collagen and Optifoam dressing. However, the CNA applied the dressing and ointment, which was not within her scope of practice. The RN admitted to delegating the task to the CNA when busy, which is against the facility's policy and state regulations that require a licensed nurse to perform such tasks. Additionally, the facility did not coordinate hospice care effectively for two residents. One resident developed a pressure ulcer on the coccyx, and the nursing staff did not assess or obtain treatment orders, assuming hospice was managing the wound. The DON was unaware of the pressure ulcer and expected staff to conduct assessments and obtain orders regardless of hospice involvement. This lack of coordination and communication led to inadequate care for the resident. Furthermore, another resident experienced unmanaged pain during repositioning, despite having orders for as-needed pain management. The resident was observed in pain, but the pain assessments documented a score of 0 out of 10, leading to no administration of pain medication. Hospice staff expressed concerns about the facility's management of pain for residents, indicating a failure to recognize and address the resident's pain effectively.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement adequate pressure ulcer prevention and care measures for three residents identified as high risk for skin breakdown. Resident 10 was observed lying in bed for extended periods without repositioning, resulting in stage two pressure ulcers on both heels and an abrasion on the coccyx. Despite having a care plan that included pressure-relieving interventions, these were not consistently applied, and the resident's electronic medical record did not reflect the presence of existing pressure ulcers. Resident 12, who was on hospice care, was also not repositioned regularly, leading to the development of a Kennedy ulcer on the coccyx and an injury on the thigh. The facility staff failed to document these skin impairments in the resident's medical record, and there was a lack of communication with the primary care physician regarding the wounds. The hospice nurse assessed the wounds, but the facility did not have corresponding wound care orders or assessments documented. Resident 49, who was severely cognitively impaired and dependent on staff for mobility, was not repositioned every two hours as required. This resulted in the development of stage two pressure ulcers on the coccyx and buttocks. The facility's Director of Nursing acknowledged that these pressure ulcers were preventable and expressed concerns about the adequacy of staff training and adherence to care protocols.
Inadequate Pain Management for Hospice Resident
Penalty
Summary
The facility failed to adequately manage pain for a hospice resident, identified as Resident 49, who was observed to be in significant discomfort during repositioning. On multiple occasions, the resident was noted to grimace, moan, and shout for help when being moved by staff, indicating unmanaged pain. Despite these observations, the resident's pain was documented as zero out of ten by nursing staff, and no pain medication was administered on the day of the observation, despite having a physician's order for Oxycodone as needed. Interviews with staff revealed that the CNAs and RNs were aware of the resident's increased pain, particularly during repositioning, and had communicated this to the nursing staff. However, the pain management plan was not effectively implemented, as the resident's pain was not adequately assessed or addressed. The hospice RN had previously requested a change to scheduled morphine for better pain control, but this was not reflected in the care provided. The resident's care plan included goals and interventions for pain management, such as administering analgesics as ordered and monitoring for effectiveness. However, the documentation and actions taken did not align with these interventions, as evidenced by the lack of pain medication administration and inaccurate pain assessments. The facility's pain management policy required regular pain evaluations and collaboration with hospice care, which were not sufficiently executed in this case.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to maintain standard food safety practices, as evidenced by unsanitary conditions in the kitchen and improper food storage. During an initial kitchen tour, surveyors observed a fan covered in dust, missing tile flooring, and a large puddle of water under the dishwasher. The dishwasher itself had a significant buildup of limescale and food scum, and the ventilation hood above it was rusted and dusty. The dietary manager admitted to being aware of the ventilation issue and lacked documentation for regular maintenance tasks like deliming the dishwasher. In the main kitchen area, the stovetop range and ovens were found to be dirty, with burnt-on food and grease. Bulk food ingredient bins were unlabeled and undated, and trash cans were left uncovered. The walk-in cooler and freezer had mold growth, damaged flooring, and food items stored improperly, such as raw bacon above milk cartons. Several food items were past their expiration dates or visibly rotting, and the emergency food supply was dusty and expired. During a meal service observation, staff members failed to follow proper hand hygiene and glove use protocols. An unidentified staff person wore the same gloves throughout the service, handling various items and serving food without washing hands. The dietary manager also failed to wash hands between tasks. Temperature monitoring for communal refrigerators was incomplete, with several slots left unrecorded. The facility's policies on food storage, glove use, and temperature monitoring were not adhered to, contributing to the deficiencies observed.
Facility Fails to Maintain Homelike Environment Due to Structural Damages
Penalty
Summary
The facility failed to maintain a homelike environment, as evidenced by significant damages observed in various areas. In a shared bathroom, the ceiling was in disrepair, with bare chicken-wire-type metal sheeting exposed and partially cut out, hanging directly above the toilet. This posed a potential hazard to residents using the bathroom. Resident 9 confirmed that the ceiling had been in this condition for an extended period. Additionally, throughout the building, there were multiple instances of structural damage, including a rusted and corroded emergency exit door frame, missing baseboards, large paint chunks missing from walls, peeling wallpaper, stained caulking, and exposed baseboard heating elements. In the therapy gym, chunks of flooring were missing, and a rubber mat was torn, creating potential tripping hazards. Interviews with staff revealed awareness of some of these issues, but there were delays in addressing them due to scheduling difficulties with contractors. The maintenance director acknowledged the bathroom ceiling issue and the damaged door frame, stating that contractors had been contacted but were unavailable. The interim administrator was aware of the flooring issues and was awaiting funding to address them. The facility's Preventative Maintenance policy, dated July 2008, was reviewed, indicating that the maintenance department was responsible for the condition and function of the physical plant, but it was not effectively implemented to prevent the deficiencies observed.
Infection Control Deficiencies in Wound and Personal Care
Penalty
Summary
The report details multiple deficiencies in infection prevention and control practices at a long-term care facility. A registered nurse (RN) failed to follow proper hand hygiene and wound care protocols while treating several residents with wounds and catheters. The RN did not perform hand hygiene between glove changes and did not use barriers under wound care supplies, which were placed on unclean surfaces. Additionally, the RN did not use enhanced barrier precautions (EBP) or personal protective equipment (PPE) as required for residents with wounds and catheters. Certified nursing assistants (CNAs) also failed to adhere to infection control practices. They did not sanitize their hands before donning PPE and handled clean and contaminated items with the same gloves. This included using the same towels for different parts of a resident's body, which could lead to cross-contamination. The CNAs did not follow proper procedures for personal hygiene and catheter care, increasing the risk of infection for the residents. The facility's environment also contributed to the deficiencies. The whirlpool tub and therapy gym equipment were not maintained in a cleanable condition, with visible dirt and corrosion. The Director of Nursing, who is also the infection preventionist, acknowledged the lack of training and competencies in wound care and infection control among staff. The facility's policies on enhanced barrier precautions and hand hygiene were not consistently followed, leading to potential risks of infection for the residents.
Failure to Update Care Plan for Resident with Pressure Ulcers
Penalty
Summary
The provider failed to revise and update the care plan for a resident with pressure ulcers on both heels and an abrasion on the coccyx. The resident was observed in bed with a catheter and a feet elevation cushion that was not positioned correctly, allowing his heels to touch the bed. Interviews with the RN and DON confirmed that the resident had stage II pressure ulcers on both heels and a superficial abrasion on the coccyx, but these conditions were not reflected in the care plan. The care plan, last updated several months prior, did not include any mention of the current pressure ulcers or abrasions. The facility's policy required that care plans be updated to reflect any new skin impairments, but this was not done for the resident in question. The DON acknowledged the oversight and agreed that the care plan did not reflect the resident's current skin integrity needs. The facility's skin integrity policy outlined procedures for assessing and documenting skin conditions, but the care plan failed to incorporate these updates, leading to a deficiency in care planning for the resident's pressure ulcers.
Deficiencies in Pressure Ulcer Prevention and Infection Control
Penalty
Summary
The provider failed to identify and correct quality deficiencies related to pressure ulcer prevention and treatment, infection control, and pain management. The medical director was aware of some residents having pressure ulcers and completed rounds once a month, but he did not know all the details about the facility's processes and was not aware that the facility lacked a repositioning policy. The director of nursing, who served as the QAPI advisor, acknowledged the need for improvement in infection control, wound care, and enhanced barrier precautions. Additionally, there were issues with the attendance of interdisciplinary team meetings, which were crucial for resident care updates. The facility's QAPI plan included performance improvement projects focused on maintenance, dietary cleaning, labeling, and dating, but did not adequately address the critical areas of pressure ulcer prevention, infection control, and pain management. The QAPI training was not completed by all assigned staff, and there were environmental issues such as missing ceiling tiles, uncleanable surfaces, and dirty equipment in therapy rooms. These deficiencies indicate a lack of comprehensive and effective implementation of the QAPI process to address and monitor critical areas affecting resident care.
Deficiency in Walk-in Cooler and Freezer Maintenance
Penalty
Summary
The provider failed to maintain the walk-in cooler and freezer in a functioning manner that met industry standards. During an observation and interview in the kitchen with the dietary manager, it was noted that the walk-in cooler door did not seal properly, allowing light from the hallway to be visible and creating a gap large enough to poke several fingers through. Additionally, there was an abundance of unidentified black and white fuzzy growth, likely mold, on the walls, door frame, floor, and shelving units, which could be due to improper temperature control. In the walk-in freezer, there was ice buildup on the ceiling and floor, indicating improper temperature control, and a side panel of the condenser was hanging unsecured, blowing hot air and melting the ice buildup. The dietary manager was aware of these issues. Follow-up interviews with the dietary manager were attempted but he was not available.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The provider failed to protect two residents from physical, mental, and verbal abuse by a certified nursing assistant (CNA). The abuse included incidents where the CNA was witnessed kicking a resident in the shin and placing a washcloth over another resident's mouth to quiet them. Both residents involved had dementia, which made it difficult to assess them for psychosocial harm. Despite staff reporting these incidents, the provider allowed the CNA to continue working without taking immediate protective measures. The provider did not conduct a thorough investigation into the allegations of abuse. Although the director of nursing (DON) was informed of the concerns, she did not document any investigation or resident assessments. The executive director (ED) and DON both denied initial knowledge of the abuse allegations, but later confirmed awareness of specific incidents. The provider also failed to report the incidents to the necessary entities in a timely manner, as required by their abuse and neglect policy. The facility's policies and procedures for preventing and responding to abuse were not followed. The DON did not suspend the CNA pending investigation, and the allegations were not reported to the required state agencies. Additionally, the facility's abuse prohibition policy was not adhered to, as the investigation was not documented, and the residents were not adequately protected from further harm during the investigation process.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The provider failed to notify the required entities of allegations of physical, mental, and verbal abuse by a certified nursing assistant (CNA) towards two residents. The provider learned about concerns regarding the care and services a CNA was providing to residents but failed to protect the residents from potential further abuse during the investigation by allowing the CNA to continue working. The provider did not gather more information from the reporting party to understand the extent of the situation and failed to report the incidents to the necessary entities. The CNA was suspended pending investigation, but the initial report to the Department of Health (DOH) was delayed. The provider conducted an investigation into the allegations, including assessing the residents involved for injuries, but nothing was documented. Witness statements from other CNAs indicated that the alleged perpetrator had a history of abusive behavior, which improved temporarily after being addressed by administration but then reverted. The provider failed to conduct a thorough investigation and did not follow their abuse/neglect policy. Interviews with staff revealed that some were aware of the incidents but were initially afraid to report due to fear of retaliation. The Director of Nursing (DON) and Executive Director (ED) were aware of the allegations but did not report them to the required entities. The DON was not aware of the reporting requirements and the provider's abuse and neglect prohibition policy. The provider's failure to report and investigate the allegations promptly and thoroughly led to the deficiency.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The provider failed to thoroughly investigate allegations of physical, mental, and verbal abuse by a certified nursing assistant (CNA) towards two residents. The incidents involved the CNA allegedly kicking a resident in the shin and placing a washcloth over another resident's mouth to quiet them. Both residents involved have dementia, which made it difficult to assess them for psychosocial harm. Despite being aware of these allegations, the provider allowed the CNA to continue working an overnight shift, thereby failing to protect the residents from potential further abuse. The provider did not report the incidents to the necessary entities in a timely manner and failed to conduct a thorough investigation. The initial report to the Department of Health was not submitted until several days after the allegations were first brought to the attention of the executive director (ED) and director of nursing (DON). Interviews with the ED and DON revealed that they were aware of the allegations but did not take immediate action to investigate or report them. The DON admitted to not being aware of the provider's policy on investigating allegations of abuse. The investigation process was inadequate, as the DON only interviewed a small sample of residents and did not document the interviews. The CNA accused of abuse denied the allegations, and the ED and DON felt their investigation was satisfactory despite the lack of documentation and thoroughness. The provider's failure to follow their abuse/neglect policy and to take immediate action to prevent further potential abuse contributed to the deficiency.
Inadequate Administration and Abuse Allegations
Penalty
Summary
The facility failed to ensure the safety and well-being of its residents due to inadequate administration by the Executive Director (ED) and Director of Nursing (DON). The administration did not maintain an effective abuse and neglect prohibition program, as evidenced by their failure to follow policies and procedures related to mandatory reporting and investigations of abuse allegations. Specifically, there were allegations of physical, verbal, and mental abuse by a Certified Nursing Assistant (CNA) towards two residents, which were not reported or thoroughly investigated by the ED and DON. Interviews revealed that both the ED and DON initially denied knowledge of these allegations, and the investigation was insufficient, lacking documentation and comprehensive interviews with staff and residents. Additionally, the facility did not uphold residents' rights to personal privacy. An anonymous staff member used a cellphone to secretly record private resident conversations, intending to provide proof of residents' concerns about their care. This recording was shared with the ED, who was aware of the situation but did not take appropriate action. The failure to protect residents' privacy and address their concerns further highlights the administration's inability to manage the facility effectively. The report also indicates that the DON allowed the implicated CNA to continue working despite being aware of the abuse allegations, potentially putting residents at further risk. The DON was not familiar with the facility's abuse and neglect policy, which required the suspension of staff pending investigation. The divisional director of clinical operations confirmed that the ED was placed on suspension for failing to follow the provider's policy regarding abuse prevention and investigation. The ED was supposed to act as the abuse coordinator, responsible for overseeing the implementation of policies to prevent abuse and neglect, but failed to fulfill these duties.
Violation of Resident Privacy Due to Unauthorized Recordings
Penalty
Summary
The provider failed to uphold a resident's right to personal privacy for at least three residents due to an anonymous staff member using their cellphone to secretly record private resident conversations. The South Dakota Department of Health received a complaint detailing allegations of abuse by a certified nursing assistant (CNA), which included audio recordings of private conversations of residents. The anonymous staff member recorded these conversations to gather evidence of the alleged abuse to present to the administration. Interviews with the director of nursing and the executive director revealed initial denials of any recent allegations of abuse or neglect by staff. However, upon further questioning, the executive director acknowledged that a staff member had mentioned concerns about a CNA being rough with residents. The anonymous staff member who made the recordings confirmed that they had shared the recordings with the executive director, although the executive director did not initially mention the recordings. The provider's policies, including the employee handbook and code of conduct, prohibit unauthorized recordings and emphasize the importance of maintaining resident privacy. The anonymous staff member was placed on suspension pending investigation for secretly recording resident conversations, which violated the Health Insurance Portability and Accountability Act (HIPAA) and the company's policies. The staff member had been trained on resident rights, HIPAA, and abuse prohibition, and had acknowledged receipt of the employee handbook and code of conduct.
Failure to Investigate Elopement of At-Risk Resident
Penalty
Summary
The provider failed to ensure a thorough investigation was completed for a resident identified at risk for elopement who successfully left the facility without staff knowledge. The resident, who had a history of dementia with behavioral disturbances and was an active exit seeker, was found approximately a half mile away from the facility and returned by staff. Despite having a Wanderguard device that was functioning and monitored every shift, the resident managed to exit the building when a wheelchair transit driver entered a code to return another resident from an appointment. Staff misinterpreted the situation, assuming the alarm was related to the transit activity, and turned off the alarm. The resident had been assessed as at risk for elopement on multiple occasions and had a history of frequent attempts to leave the facility. His medical records indicated moderate cognitive impairment, and he had been actively seeking exits, as noted in various care conference notes and alert charting. Despite these indicators, the facility's response to the alarm was inadequate, leading to the resident's unsupervised departure. The incident was reported the following morning at a staff meeting, and it was noted that the resident was found pushing his wheelchair several blocks away from the facility. Interviews with staff revealed a lack of clarity and communication regarding the elopement incident. The Director of Nursing, who had recently assumed the role, acknowledged the need for a more thorough investigation and had heard conflicting reports from staff about the incident. The facility's elopement policy defined elopement as a resident exiting the center without staff knowledge, which occurred in this case. The deficiency highlights a failure in the facility's procedures to prevent and adequately respond to elopement risks, particularly for residents with known cognitive impairments and exit-seeking behaviors.
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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