Sanford Care Center Vermillion
Inspection history, citations, penalties and survey trends for this long-term care facility in Vermillion, South Dakota.
- Location
- 125 S Walker Street, Vermillion, South Dakota 57069
- CMS Provider Number
- 43A098
- Inspections on file
- 20
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Sanford Care Center Vermillion during CMS and state inspections, most recent first.
The facility failed to protect two cognitively impaired, elopement-risk residents from leaving the building without staff knowledge. One resident with dementia, agitation, and a roam alert was wandering and exit seeking at night; after a door alarm sounded, an RN moved to reset it, and the resident pushed through the south exit door and left the building unsupervised. Staff reported ongoing aggressive and exit-seeking behaviors, ineffective PRN anxiety medication, lack of training on managing such behaviors, and no participation in elopement drills, with close visual checks only started after the incident. A second resident on hospice with dementia, behavioral disturbances, and a roam alert was tearful, pacing, repeatedly packing to leave, and verbally expressing a desire to go; staff observed she had removed her window screens and were told to keep an eye on her, but no increased monitoring or PRN anxiolytics were used. She subsequently removed a window screen, pried the window open, crawled out, and was found by police several blocks away, demonstrating inadequate supervision and hazard control for residents at risk of elopement.
A cognitively impaired resident with dementia and hearing loss, who frequently repeated requests and used the call light, was subjected to verbal abuse when a CNA allegedly told her to “shut the [expletive] up” in response to her calling out. A cognitively intact resident with an above-knee amputation, depression, and PTSD, whose room was across the hall, reported hearing the exchange and then seeing the CNA standing by the resident’s room, and multiple staff described this witness as reliable. Staff interviews further revealed that the CNA had appeared irritated and rude that shift, and an LPN reported a prior unreported incident in which the same CNA yelled at another resident. The facility’s abuse policy prohibits disparaging or derogatory language within a resident’s hearing, establishing that the resident was not protected from verbal abuse.
A resident with a history of self-harm was found with multiple open wounds and sharp instruments in his room. Despite staff awareness of his behavior and possession of sharps, the resident was allowed to keep these items, leading to inadequate supervision and prevention of self-harm. The resident's care plan permitted him to have sharps, and staff interviews revealed a lack of intervention to prevent his actions.
A resident with a history of self-inflicted wounds was observed with multiple open areas and active bleeding on his legs, managing his own wound care without proper education from facility staff. Nursing staff expressed concerns about the resident's self-harming behavior and the lack of proper wound care documentation. The care plan allowed the resident to keep sharps in his room, but it lacked effective interventions to prevent self-harm and ensure proper wound care, resulting in a deficiency.
The facility's assessment failed to address staffing resources necessary for resident care. The assessment, an eleven-page Excel spreadsheet, included analyses of census, care needs, and medical conditions but did not specify staffing requirements or scheduling. Interviews with the DON and MDS nurse confirmed the omission, and the administrator acknowledged the lack of a connection between the assessment and staffing needs.
A facility failed to maintain a physician's order consistent with a resident's advance directive. The resident's EMR showed a DNR status, but a full code order was in place. The DON and MDS nurse were aware of the issue, but no updated order was obtained from the physician. The facility's policy requires specific and updated orders for life-sustaining measures.
The facility failed to maintain the memory care unit's pantry refrigerator temperature below 41 degrees F, as required. Observations showed temperatures of 46 and 50 degrees F, with incomplete temperature logs for several months. Staff interviews revealed confusion over monitoring responsibilities, and the director of nursing confirmed the night nurses' duty to check temperatures was not consistently performed.
A shared blood glucose meter was not properly cleaned and disinfected between uses for two residents, increasing the risk of bloodborne pathogen infections. The RN used a gray top Sani-cloth wipe but did not follow the correct procedure, failing to allow the meter to remain wet for the required contact time. Interviews revealed staff were unaware of the proper cleaning process, which was outlined in the facility's policy and the meter's user manual.
Two residents were found with medications improperly stored at their bedsides without orders, and a resident with severe cognitive impairment fell from a mechanical lift due to improper use. The resident's care plan specified a total mechanical lift, but staff used an EZ sit-to-stand lift without securing the leg belt. Interviews revealed a lack of adherence to care plans and communication among staff.
Failure to Prevent Elopement of Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for two residents identified as elopement risks, both of whom left the building without staff knowledge. The first resident had severe cognitive impairment with a BIMS score of 0 and diagnoses including unspecified dementia with agitation, depression, anxiety disorder, alcohol abuse in remission, ADHD, and insomnia. He had been assessed as at risk for elopement and wore a roam alert device. On the night of the incident, he was wandering, exit seeking, and exhibiting agitation and threats against staff. Despite these behaviors and his known history of aggression and exit seeking, he was able to push open a south exit door and leave the building at approximately 12:42 a.m. after the door alarm sounded and the RN moved toward the door to reset the alarm. The nurse reported she could not see him outside, immediately called 911, and did not send staff out to search due to concerns for staff safety and the dark conditions. The first resident’s behaviors had been ongoing, including exit seeking and aggressive actions toward staff, and he required significant one-to-one attention. Staff reported that PRN anxiety medication had been administered earlier in the evening but was ineffective, and attempts at distraction, food, and redirection were used. However, the RN stated she had never been trained by the facility to deal with that type of behavior, and both she and a CNA reported they had not participated in any elopement drills during their years of employment. The facility’s elopement policy existed, but education provided after the first elopement focused on assessment rather than on what to do during an actual elopement event. Fifteen-minute visual checks for this resident were not initiated until after the elopement occurred, despite his known elopement risk and severe cognitive impairment. The second resident also had severe cognitive impairment with a BIMS score of 3 and diagnoses including unspecified dementia with behavioral disturbances, anxiety disorder, diabetes, and a history of falls. She was on hospice at admission, identified as an elopement risk, and had a roam alert device applied. On the day of her elopement, she was tearful over her husband’s recent death, pacing the hallways, repeatedly packing her belongings to leave, verbalizing a desire to leave, and was visibly upset. Staff observed that she had removed the inner screens from her room windows and notified a clinical care leader, who instructed staff to keep an eye on her and stated that, without window cranks, she could not do anything further. No 15-minute visual checks were initiated by floor staff, and although she had PRN lorazepam orders, no PRN doses were documented as given that day. Later that evening, staff were notified by police that the second resident had left the building and was found approximately five blocks away. She had removed the screen from her window, pried the window open enough to crawl out, and exited the building without staff knowledge. At the time of her elopement, the outside temperature was about 24 degrees, and she was dressed in layered clothing with sandals and socks and had a blanket with her. The DON later stated that staff should have been concerned when the resident removed her window screens. Interviews revealed that while some nurses had received elopement education after the first resident’s elopement, there had been no further elopement education for staff following the second resident’s elopement, and the DON was unsure when the last elopement drill had been completed. These actions and inactions resulted in two residents at known risk for elopement leaving the facility without staff supervision.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. A cognitively intact resident with a history of left leg above-knee amputation, depression, and post-traumatic stress disorder reported overhearing a male CNA tell another resident to “shut the [expletive] up” while responding to that resident’s repeated requests. The resident who was the target of the alleged verbal abuse had severe cognitive impairment with a BIMS score of 3, dementia, hearing loss, and chronic kidney disease stage 3, and was known to be impatient, verbally repetitive, and demanding of staff. On the evening in question, the cognitively intact resident was in her room across from the cognitively impaired resident’s room, heard the impaired resident repeatedly calling out and using her call light, and then heard a male voice respond with the profane directive. The cognitively intact resident wheeled herself to her doorway and observed the identified CNA standing by the cognitively impaired resident after hearing the profane statement. She later reported this to facility staff, stating she recognized the CNA’s voice and confirming his presence at the scene. The social worker interviewed both residents the following day; the cognitively impaired resident did not recall the incident and reported feeling fine, while the cognitively intact resident consistently described hearing the CNA tell the other resident to “shut the [expletive] up” and reiterated that the other resident had been calling out and demanding immediate help. Multiple staff, including the DON, LPN, and RN, described the cognitively intact resident as a reliable and truthful reporter. Additional staff interviews and record reviews supported concerns about the CNA’s interactions with residents. A CNA coworker reported that on the evening of the incident the CNA appeared irritated, overwhelmed, and in a bad mood, and that he had been rude to her, though she had not previously heard him swear at residents. An LPN reported having previously observed the same CNA yell at an exit-seeking resident and stated she had used that prior event as a teaching moment, but she had not reported it to management at the time. The facility’s abuse and neglect policy defines verbal abuse as the use of disparaging or derogatory language within a resident’s hearing, regardless of the resident’s ability to comprehend, and states that residents have the right to be free from verbal abuse by anyone. The incident as reported and corroborated by staff interviews demonstrates that the resident was subjected to verbal abuse in violation of this policy and resident rights.
Inadequate Supervision Leads to Resident Self-Harm
Penalty
Summary
The provider failed to provide adequate supervision for a resident to prevent actions of self-harm. The resident was observed in his room with multiple open areas on his bilateral lower legs, some of which were actively bleeding, while holding a sharp instrument. Staff interviews revealed that they were aware the resident had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. The resident's care plan allowed him to have sharps in his possession to remove perceived bugs from his skin. The resident had a history of picking at his skin and cutting himself, believing there were bugs under his skin. He had been seen by a behavioral counselor due to suicidal ideations and hallucinations. Despite this, the resident was allowed to keep sharps in his room, and staff were aware of his behavior but did not adequately supervise or intervene to prevent self-harm. Interviews with staff indicated that the resident was independent, allowed to leave the premises, and would purchase items, including sharps, from a store. The resident's care plan documented his behavioral symptoms, including cutting and picking at his skin, and allowed him to keep sharps in his room. The care plan noted that the resident declined to follow physician-recommended advice and would not allow nurses to care for his open areas. Staff were aware of the resident's behavior and the presence of sharps in his room, but there was no inventory or tracking of the sharps, and the resident's wounds were not regularly documented or treated by nursing staff.
Removal Plan
- All sharps have been removed from Resident 20's room.
- Psychiatry, primary care provider and counselor have been notified for guidance in managing any adverse behavioral changes.
- Resident 20 has been re-educated on hand hygiene, sharps in his room, infection prevention to include covering wounds.
- Updates to the care plan include removing sharps, offering tubi-grips for arms and lower legs for covering of wounds when leaving his room, handwashing education, wound assessment completed, one-hour check while in the facility for behaviors given resident psychiatric history then re-evaluate.
- Center of Excellence for Behavioral Health in Nursing Facilities contacted with expected response.
- Director of nursing spoke to Resident 20 about dressing changes.
- Resident agreed to let nursing staff change dressing twice a day.
- Nursing staff will monitor for any signs of infection during dressing changes and notify the physician if any noticed. These will be documented on Resident 20's treatment.
- Nursing will remove soiled towels and washcloths when in his room providing dressing changes. This has been included in the treatment plan and added to the certified nursing assistant (CNA) flowsheet.
- Resident was informed that he would not need to buy wound/dressing supplies.
- Sharps removed from resident 20's room.
- All other current resident rooms were checked for sharps and any of concern were removed.
- Discussed with Resident 20 that his bags would be checked upon return from shopping.
- Resident signed previous acknowledgment form that he agreed to staff removing sharps that he may bring back.
- Staff will conduct random room checks and will chart in Resident 20's chart as a treatment.
- This has been added to Resident 20's treatment plan and CNA flowsheet.
- Added a treatment order for nursing documentation for behavior/mood of resident 20.
- Resident 20's behavior documentation will be reviewed at interdisciplinary team (IDT) meetings and as needed with adjustments to care/treatment plan as warranted.
- Admission packet updated regarding review of sharps for safety.
- Resident 20's primary contacts have been re-educated on notifying staff prior to bringing/getting sharps items to resident via email.
- Resident 20 has been re-educated on proper hand hygiene for infection prevention and sharps.
- Staff have been re-educated on sharps in rooms and planned review of infection prevention practices related to transmission through OnShift.
- They receive this education annually at minimum.
- A skills fair reviewing infection prevention is scheduled and annually for staff.
- Sharps restriction added to admissions packet.
- Staff re-educated on infection prevention practices and safety of all residents related to sharps in resident rooms.
- Staff were educated through onshift message about the removal of sharps for any resident.
- Additional education provided to nursing staff related to resident 20 returning from shopping, the need to look in resident 20's bags for any sharp objects that staff would need to remove and secure in the medication room, staff will reiterate to resident that he is not able to have those items in his room.
- PRN treatment order added to check bags upon returning from shopping outings.
- Staff will also be educated on the random room checks that will be conducted on Resident 20's room for sharps found, those items will be removed and secured in the medication room.
- Treatment order added to document these random room checks for Resident 20, also added to CNA flowsheet to check room twice a day.
Inadequate Wound Care and Monitoring for Resident with Self-Harming Behavior
Penalty
Summary
The provider failed to deliver appropriate wound care, assessment, and monitoring for a resident with a history of self-inflicted wounds. The resident was observed with multiple open areas and active bleeding on his lower legs, with bandages on some of them. He was found to be managing his own wound care, using alcohol and Neosporin, without proper education from the facility staff. The resident had a history of a picking disorder and was known to use sharps to cut his skin, which was care planned but not adequately monitored or controlled by the facility. Interviews with nursing staff revealed concerns about the resident's self-harming behavior and the lack of proper wound care documentation. The resident was allowed to keep sharps in his room, and there was no inventory or count of these items. Staff expressed concerns about the potential for infection and the resident's refusal to allow nurses to care for his wounds. Despite being aware of the resident's behavior, the facility did not have a comprehensive plan to address the risks associated with his self-care practices. The resident's care plan acknowledged his behavioral symptoms and the presence of sharps in his room, but it lacked effective interventions to prevent self-harm and ensure proper wound care. The care plan allowed the resident to have sharps due to his refusal to comply with facility policies, and there was no evidence of consistent education or intervention to mitigate the risks. The facility's failure to provide appropriate wound care and monitoring resulted in a deficiency in the care provided to the resident.
Facility Assessment Lacks Staffing Resource Details
Penalty
Summary
The facility failed to ensure that their facility-wide assessment adequately addressed the staffing resources necessary to provide appropriate care and services to residents. The assessment, which was an eleven-page Excel spreadsheet, included various analyses such as a monthly trending analysis of census, physical function and care needs, and medical diseases and conditions of residents. However, it did not specify the number of staff required to care for the residents or how they would be scheduled or assigned. Additionally, the assessment lacked details on how residents' medical and mental health diagnoses would impact their care needs and the level of assistance required from staff. Interviews with the Director of Nursing and the Minimum Data Set nurse confirmed that the facility assessment did not include or address staffing needs. The administrator also acknowledged that there was no connection between the spreadsheet and the staffing needed to ensure appropriate care and services for residents, including the competencies required of staff. Furthermore, there was no specific policy on the process for conducting the facility assessment.
Failure to Maintain Consistent Advance Directive Orders
Penalty
Summary
The provider failed to maintain a physician's order consistent with a resident's advance directive. A review of the electronic medical record (EMR) for one resident revealed a discrepancy between the displayed do not resuscitate (DNR) status and a full code order, which permits life-sustaining measures, including resuscitation. The director of nursing (DON) and the Minimum Data Set (MDS) nurse were interviewed, and it was found that the DON did not have a current DNR order for the resident. The MDS nurse had faxed the physician to request an order but had not received one. The provider's advance directive policy requires that advance directive orders be reviewed with the resident or healthcare decision-maker at each care plan meeting and that any changes be documented and communicated to the physician for updated orders. The policy also specifies that physician's orders must be specific regarding life-sustaining measures.
Failure to Maintain Proper Refrigerator Temperature in Memory Care Unit
Penalty
Summary
The provider failed to maintain the temperature of the memory care unit's pantry refrigerator below 41 degrees Fahrenheit, as required by professional standards. On multiple occasions, the refrigerator's temperature was observed to be above the acceptable range, with readings of 46 degrees F and 50 degrees F on consecutive days. The temperature logs for the refrigerator were incomplete, with no documented temperatures for several months, including December 2023 and June 2024. Interviews with staff revealed a lack of clarity regarding the responsibility for monitoring and recording the refrigerator's temperature, contributing to the oversight. The director of nursing acknowledged that the night nurses were responsible for checking the refrigerator temperatures, but the task had not been consistently performed. The absence of completed temperature logs for several months indicated a systemic failure in monitoring the refrigerator's temperature. The facility's policy required daily monitoring and logging of refrigerator temperatures, with specific actions to be taken if temperatures exceeded the acceptable range. However, these procedures were not followed, leading to the deficiency in maintaining proper food storage conditions.
Improper Cleaning of Shared Blood Glucose Meter
Penalty
Summary
The provider failed to properly clean and disinfect a community-shared blood glucose meter, which was used for two residents, leading to a potential increased risk for bloodborne pathogen infections. During an observation, a registered nurse (RN) used a gray top Sani-cloth wipe to clean the glucose meter after checking the blood glucose levels of one resident and then used the same meter for another resident without following the correct cleaning procedure. The RN was unaware of the specific policy for cleaning the glucose meter and did not allow the meter to remain wet for the required contact time as per the manufacturer's instructions. Interviews with the clinical learning and development specialist and the director of nursing revealed that the staff did not adhere to the proper cleaning process, which involved using a wipe to clean visible blood or fluids and then another wipe to ensure the meter remained wet for the appropriate contact time. The facility's policy and the glucose meter's user manual specified the need for cleaning and disinfecting the meter after each use, with a contact time of three minutes for the gray top Sani-cloth. The failure to follow these procedures was confirmed through interviews and a review of the facility's policy and the manufacturer's instructions.
Medication Storage and Transfer Protocol Deficiencies
Penalty
Summary
The report identifies deficiencies in the storage and administration of medications for two residents in the facility. Resident 16 was found with two boxes of eye drop medication on his bedside table, which were left by a nurse and not retrieved. The resident, who was cognitively intact, did not have an order for self-administration of these medications. Similarly, Resident 2 had a container with various lotions and ointments on a stand next to his recliner, without an order for these items to be at the bedside. Interviews with the LPN and the Director of Nursing confirmed that there were no orders for medications to be left at the bedside, except for cough drops, and that Resident 16 did not have such an order. The report also details an incident involving Resident 37, who fell from a mechanical lift due to improper use. The resident, who had severe cognitive impairment and a history of falls, was being transferred using an EZ sit-to-stand lift without the leg belt secured. This was contrary to his care plan, which specified the use of a total mechanical lift for all transfers. The incident occurred while two CNAs were assisting the resident, and it was noted that the staff had not read the care plan to verify the correct transfer method. The resident had previously experienced fainting-like spells when using the sit-to-stand lift, and a note was posted in his room to use the total mechanical lift instead. Interviews with staff revealed a lack of consistent communication and adherence to care plans. CNA I admitted to not reading the care plan and following the previous shift's method, while CNA H, a PRN staff member, was unaware of the updated transfer instructions. The Director of Nursing acknowledged the absence of lift assessments and a policy for determining the appropriate lift device. The MDS nurse admitted to possibly forgetting to update the care plan date and was unaware of any fainting-like episodes before the incident. The facility's policy and the manufacturer's manual for the lift devices were reviewed, highlighting the need for proper assessment and adherence to care plans for safe resident handling.
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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