Sanford Chamberlain Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chamberlain, South Dakota.
- Location
- 300 S Byron Blvd, Chamberlain, South Dakota 57325
- CMS Provider Number
- 43A073
- Inspections on file
- 23
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sanford Chamberlain Care Center during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with severe cognitive impairment experienced multiple falls and was handled roughly and restrained by a CNA, who failed to notify a nurse or request assistance. Several staff members, including an LPN and other support staff, witnessed the incidents but did not intervene or report the abuse. The resident was not assessed after the falls, and staff failed to follow required protocols. Training records showed that many staff had not received abuse and neglect education, and facility policy on reporting abuse was not followed.
Two residents with severe cognitive impairment and a history of falls experienced repeated falls, including one resulting in a hip fracture, due to the facility's failure to update care plans and implement new fall prevention interventions after each incident. Staff did not consistently document or apply new strategies, and there was confusion about where to find or how to update fall interventions in the EMR, despite management expectations and facility policy.
Two residents with severe cognitive impairment experienced multiple changes in condition, including repeated falls and changes in transfer and hospice status, but their care plans were not updated to reflect new interventions or current needs. Staff interviews revealed inconsistent understanding of care plan responsibilities, and documentation showed that required updates and interventions were often missing or incomplete.
A facility failed to implement an action plan after a resident with cognitive impairment became aggressive, striking another resident. Staff lacked adequate training to manage dementia-related behaviors, relying on online courses without hands-on training. Additionally, there was insufficient communication of care plan updates, leaving staff unprepared to handle the resident's unpredictable behavior.
A resident fell and suffered head trauma while attempting to sit on a whirlpool chair due to the brakes not being locked by a CNA. The resident, who had a history of falls and required supervision for bathing, sustained injuries and required emergency room treatment. The CNA had been trained on safety measures, but there was no signage in the tub room about locking the chair wheels, and the manufacturer's instructions were not readily available.
A resident with severe cognitive impairment and a history of dehydration was found to have inadequate fluid intake, leading to dehydration and a urinary tract infection. Despite water being available, fluid intake was not consistently documented, and the resident's intake was significantly below recommended levels. The resident also experienced significant weight fluctuations, with no follow-up on documented weight loss, highlighting a deficiency in care.
A resident with severe cognitive impairment and a history of frequent falls did not receive the required neurological checks after a fall, as per the facility's policy. The resident, who had multiple diagnoses including Tourette's and prostate cancer, was later diagnosed with rib fractures, a UTI, and dehydration. The facility's policy mandated specific neurological checks following unwitnessed falls, which were not documented as completed.
A resident with a history of trauma expressed fear and suicidal thoughts after an unwanted entry into her room by another resident with cognitive impairment. The facility failed to implement adequate interventions to prevent further incidents. Additionally, two residents engaged in repeated verbal and physical altercations, with insufficient interventions to prevent these incidents. The facility's abuse prevention policies were not effectively implemented, contributing to the deficiency.
A facility failed to conduct required trauma screenings for residents, including one with a history of PTSD and recent psychiatric hospitalization. The licensed social worker confirmed the screenings were not completed as required by the facility's trauma-informed care policy. Additionally, the DON did not review hospital notes for a resident returning from psychiatric care.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident fell during a transfer due to outdated care plan instructions, while another resident's care plan did not address his wandering and aggressive behavior. Additionally, a resident with PTSD and recent psychiatric hospitalization had an incomplete care plan, lacking details on her mental health needs and safety plan.
A resident with dementia and Alzheimer's disease eloped from the facility and fell, requiring emergency evaluation. Despite wearing a Wander Guard, the resident exited through the front doors without staff knowledge. The facility's interventions, including monitoring and the Wander Guard, were insufficient to prevent the incident. Staff were alerted by a passerby, but the resident had already sustained injuries. The care plan lacked specific boundaries for safe wandering, and the facility's policy required an incident report and care plan revision after elopement.
The facility failed to maintain food safety and cleanliness in two kitchenettes, with observations of unclean refrigerators, unlabeled food items, and dirty kitchen surfaces. Staff interviews revealed a lack of awareness and responsibility for cleaning and maintenance, with inconsistencies in following cleaning checklists and policies. The dietary department, responsible for these tasks, did not ensure proper labeling and dating of food items, contributing to the deficiency.
A resident with dementia and Alzheimer's disease eloped from the facility on three occasions, but two incidents were not reported to the South Dakota Department of Health as required. The Director of Nursing and the Director of Nursing Trainer initially misinterpreted these incidents as non-elopements. Upon review, it was confirmed that these incidents should have been reported, as per the facility's policy.
A resident at risk for skin injuries developed a wound on the left buttock, which was not promptly assessed or reported to the physician. The facility failed to conduct weekly skin assessments and document the wound's status, leading to inconsistencies in care. Nursing staff interviews revealed confusion in the skin assessment process, and the facility's policy on skin breakdown prevention was not effectively implemented.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Protect Resident from Physical Abuse and Staff Inaction
Penalty
Summary
A certified nursing assistant (CNA) responded to multiple falls of a resident with severe cognitive impairment by using physical force and restraint, without notifying a nurse or requesting assistance. The CNA lifted the resident from the floor alone, despite the resident resisting, and placed him roughly into his wheelchair. The CNA also locked the wheelchair brakes, preventing the resident from moving, and did not seek a nurse's assessment after the falls. Video footage confirmed these actions, and the resident was observed to have bruises on his arms corresponding to where the CNA had grabbed him. The resident displayed increased anxiety during interactions with the CNA. Eight additional staff members, including other CNAs, a licensed practical nurse (LPN), certified medication assistants (CMAs), and food service staff, were present during these incidents but did not intervene or report the abuse to a supervisor at the time. The LPN did not assess the resident after the falls, and staff did not assist the resident or stop the CNA from using rough handling. The resident was left on the floor for an extended period after one fall, and staff failed to follow protocols for post-fall assessment and safe transfer. Review of training records revealed that several staff members, including contracted travel staff and long-term employees, had not received required abuse and neglect training. Documentation of abuse and neglect training was missing for multiple staff, and recent staff meetings and training sessions did not include education on abuse or neglect. The facility's policy required all staff to report suspected abuse or neglect, but this was not followed during the incidents described.
Failure to Revise and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement, review, and revise fall prevention interventions for two residents with a history of falls, resulting in repeated falls and injury. One resident, who was severely cognitively impaired and had recently been evaluated by physical therapy, experienced a change in transfer status but this was not updated in the care plan. After a fall that resulted in a hip fracture, there was no evidence that new or revised interventions were implemented or documented, and the care plan was not updated to reflect changes in transfer needs or fall prevention strategies. Additionally, the resident's admission to hospice and the need for an air mattress overlay were not reflected in the care plan, and recommended interventions such as increased toileting were not added after previous falls. Another resident, also severely cognitively impaired with multiple neuropsychiatric diagnoses, experienced at least 15 falls over a two-month period, including four falls in a single day. Video footage showed that after each fall, the resident was returned to the same position without new interventions to prevent further incidents. Staff did not consistently document or implement new fall prevention measures after each event, and the care plan was not updated with additional interventions despite repeated falls. Some incident reports lacked any documented interventions, and post-fall investigation tools were often incomplete. Interviews with staff revealed a lack of training and uncertainty about where to find or how to update fall interventions in the electronic medical record. While there was an expectation from management that care plans be updated in real time after a fall, staff reported not receiving education on this process and not routinely referencing the care plan for fall interventions. The facility's policy required interdisciplinary review of falls and implementation of new interventions, but this was not consistently followed in practice.
Failure to Update and Revise Care Plans After Changes in Resident Status and Falls
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current care needs for two residents. For the first resident, who had severe cognitive impairment and multiple diagnoses including dementia, Alzheimer's disease, and Parkinson's disease, there were repeated falls over a two-month period. Despite multiple falls and high fall risk assessments, the care plan was not updated with new interventions after several incidents. Documentation showed that interventions were either not implemented or not recorded after many of the falls, and post-fall investigation tools were often left incomplete. The care plan was only updated after a significant delay, and did not reflect the ongoing changes in the resident's condition or the interventions that were (or should have been) put in place following each fall. For the second resident, who was also severely cognitively impaired and had a history of falls, the care plan was not updated to reflect changes in transfer status, fall prevention interventions, or hospice status. After a change in transfer method and two falls—one resulting in a hip fracture—there was no evidence that the care plan was revised to include new interventions or to address the resident's current needs. Additionally, the care plan still referenced equipment (an air mattress overlay) that was no longer in use, and did not reflect the resident's re-admission to hospice services. Interviews with staff revealed confusion and inconsistency regarding who was responsible for updating care plans and how interventions were communicated. While some staff referenced the care plan in the electronic medical record to guide care, others were unsure where to find updated interventions. The facility's policy required care plans to be revised as residents' needs changed, but this was not consistently followed, resulting in care plans that did not accurately reflect the residents' current care requirements.
Failure to Implement Action Plan and Training for Aggressive Resident
Penalty
Summary
The facility failed to implement a plan of action following an incident where a resident with cognitive impairment became physically aggressive, striking another resident in the face. The aggressive resident's behaviors were described as impulsive and unpredictable, posing a potential risk to both residents and staff. Despite the severity of the incident, there was no immediate plan or education provided to staff on how to manage such behaviors effectively. Additionally, the facility did not ensure that staff were adequately trained to handle residents with dementia and psychosocial behaviors. Interviews with staff revealed that their training on dementia and abuse was primarily conducted online, with no additional hands-on training provided. This lack of comprehensive training left staff unprepared to manage the aggressive behaviors of the resident, leading to a situation where staff and other residents were at risk. Furthermore, the facility failed to ensure that all direct caregivers were informed of updated care plan changes for residents. Staff interviews indicated a reliance on verbal communication for care plan updates, with no formal documentation or process in place to ensure all staff were aware of changes. This lack of communication and documentation contributed to the inadequate handling of the resident's aggressive behavior, as staff were not fully informed of the appropriate interventions to use.
Resident Falls Due to Unlocked Whirlpool Chair Brakes
Penalty
Summary
The provider failed to ensure the safety of a resident who fell and suffered head trauma while attempting to sit on a whirlpool chair. The incident occurred because the brakes on the whirlpool tub chair were not locked by a certified nursing assistant (CNA), leading to the chair sliding and the resident falling forward onto her face. The resident sustained supraorbital bruises, a skin tear on her right wrist, and required emergency room treatment. The resident, who had a history of falls and was at risk due to a stroke affecting her left side, was taking multiple medications that could contribute to falls. She was independent with a front-wheeled walker but required supervision for bathing. The CNA involved had recently completed orientation and had been trained on safe resident handling, including the importance of locking brakes on equipment. However, there was no signage in the tub room indicating the need to lock the tub chair wheels, and the CNA was unaware of the location of the manufacturer's instructions. The facility's policies required the use of appropriate safety measures and adherence to manufacturer's directions for equipment operation. Despite this, the communication to staff about locking brakes on shower and bath chairs was informal, with no documentation to confirm that nursing staff had read the instructions. The incident highlights a lapse in ensuring that all staff were adequately informed and reminded of safety protocols, particularly concerning the operation of bathing equipment.
Inadequate Fluid Intake Leads to Dehydration
Penalty
Summary
The facility failed to ensure adequate fluid intake for a resident, leading to dehydration. The resident, who was severely cognitively impaired and had a history of prostate cancer, urinary tract infections, and dehydration, was found on the floor multiple times, including an incident on December 8th. Following this fall, the resident exhibited confusion, lethargy, and back pain, and was later diagnosed with rib fractures, a urinary tract infection, and dehydration at a clinic visit. Observations and interviews revealed that while water was available in the resident's room, there was no consistent documentation of fluid intake outside of meals unless the resident was on a fluid restriction. The resident's fluid intake was significantly below the recommended 1,500 ml per day, with averages ranging from 480 ml to 980 ml over different weeks in December. Additionally, there was a lack of documentation for several meals, and the nursing staff did not chart fluid intake unless specifically required. The resident experienced significant weight fluctuations, with a notable weight loss from 156 pounds to 138 pounds within a week. Despite the facility's policy to reweigh residents with significant weight changes, no daily weights were completed after the documented weight loss. Interviews with staff indicated a lack of communication and follow-up regarding the resident's nutritional and hydration needs, contributing to the deficiency in care.
Failure to Complete Neurological Checks After Resident Fall
Penalty
Summary
The provider failed to ensure that neurological checks were completed for a resident after a fall, as required by their policy. The resident, who was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 3, was found on the floor beside his bed on 12/8/24. Despite the resident's history of frequent falls and his diagnoses, including Tourette's, urinary retention, weakness, urinary tract infection, dehydration, and prostate cancer, the necessary neurological checks were not documented as completed on the day shift on 12/9/24 and 12/10/24 or the night shift on 12/9/24. The facility's policy required neurological checks to be conducted every 15 minutes for four times, every hour for two times, every two hours for two times, and every four hours for two times following an unwitnessed fall. However, these checks were not performed as per the policy. The resident was later diagnosed with three rib fractures, a urinary tract infection, and dehydration after being sent to the clinic due to the inability to collect a urine sample. The resident reported falling at least once a week and sometimes every other day, indicating a pattern of falls that required careful monitoring and adherence to the facility's fall prevention and follow-up policy.
Failure to Protect Residents from Abuse and Aggression
Penalty
Summary
The provider failed to ensure the safety and well-being of a resident with a history of trauma, who expressed feelings of fear, feeling unsafe, and suicidal thoughts after an unwanted entry into her room by another resident with cognitive impairment. This resident had previously experienced an incident where the cognitively impaired resident attempted to strangle her, causing her significant distress and fear for her safety. Despite these incidents, the facility did not implement adequate interventions to prevent further unwanted encounters, leading to the resident feeling unsafe and expressing suicidal thoughts. Additionally, the provider failed to prevent acts of verbal and physical aggression between two residents. One resident, who was cognitively impaired, had multiple altercations with another resident, including incidents where they yelled, swore, and physically attacked each other. The facility's interventions were insufficient to prevent these altercations, as evidenced by repeated incidents of aggression between the two residents. The facility's policies and procedures for abuse prevention were not effectively implemented, as evidenced by the lack of adequate interventions to protect residents from aggression and unwanted encounters. The facility's failure to review psychiatric hospital notes and update care plans further contributed to the deficiency, as staff were not adequately informed of the residents' needs and behaviors that might lead to conflict or neglect.
Failure to Conduct Required Trauma Screenings
Penalty
Summary
The provider failed to ensure that trauma-informed care was provided to residents by not conducting necessary trauma screenings. One resident, who had a history of severe depression, PTSD, and anxiety, was not screened for PTSD upon admission, quarterly, annually, or after returning from an inpatient psychiatric hospitalization for suicidal ideations. This resident had been hospitalized for suicidal thoughts and had a history of PTSD related to abuse from her first husband. Despite receiving counseling from a mental health therapist, the required trauma screenings were not completed. Two other residents also did not receive the necessary trauma screenings. One resident, with severe cognitive impairment, was not screened for trauma upon admission, quarterly, or annually, and there was no documentation indicating an inability to complete the screening. Another resident, with moderate cognitive impairment, did not receive a trauma screen upon admission or on a quarterly basis, and the annual trauma screen for 2024 was not completed, although one was done in 2023. The licensed social worker responsible for conducting trauma screenings confirmed that the screenings were not completed for these residents as required. Additionally, the director of nursing did not review the hospital notes upon the return of the resident who had been hospitalized for psychiatric reasons. The facility's trauma-informed care policy mandates trauma assessments within five days of admission and as needed, but these were not adhered to, leading to the deficiencies noted in the report.
Care Plan Deficiencies in Resident Transfers and Behavioral Management
Penalty
Summary
The provider failed to ensure that care plans were reviewed and revised for four sampled residents, leading to deficiencies in care. Resident 4 experienced a fall during a transfer when a certified nursing assistant (CNA) used a stand aid lift without the required assistance of a second staff member, as per the facility's policy. Despite the resident not being injured, the care plan was outdated and did not reflect the current requirement for a full body mechanical lift due to the resident's recent surgery and weight limitations. Resident 2 exhibited wandering behavior and had a history of physical aggression towards other residents and staff. The care plan did not include interventions to prevent him from entering other residents' rooms or address his aggressive behavior. Additionally, the care plan contained outdated information, such as the names of staff members who were no longer employed, and did not reflect the interventions staff were utilizing for his wandering and behaviors. Resident 1, who had a history of PTSD and recent psychiatric hospitalization, did not have a care plan that included her suicidal ideations, PTSD, or her safety plan. The resident expressed feeling unsafe due to an incident where Resident 2 attempted to strangle her. The facility's policies on dementia care and trauma-informed care were not adequately reflected in the care plans, leading to a lack of individualized, person-centered care for the residents involved.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The provider failed to ensure the safety of a resident who eloped from the facility without staff knowledge and subsequently fell, requiring evaluation at the emergency department. The incident occurred when the resident, who had a history of elopement and wore a Wander Guard device, exited the building through the front double doors. The Wander Guard was the primary intervention in place to prevent elopement, but it was not effective in this instance. Staff were supposed to monitor the resident closely, but there were no set times or frequencies for rounds or documentation of these checks. The resident, who had been diagnosed with dementia and Alzheimer's disease, was ambulatory and did not use assistive devices. On the day of the incident, the resident was found outside the building with lacerations on his nose and lips after tripping and falling. The facility's staff responded to the situation after being alerted by a passerby, but the resident had already sustained injuries by the time they reached him. The resident's care plan included the use of a Wander Guard and maintaining a calm environment, but it lacked specific boundaries for safe wandering. Interviews with staff revealed that the resident had previously eloped on multiple occasions, and the facility's interventions were limited to monitoring during normal rounding and the use of a Wander Guard. The facility's policy required an incident report and a revised care plan following an elopement, but the report does not detail any additional interventions or changes made to prevent future incidents. The deficiency highlights a lack of adequate supervision and effective interventions to prevent elopement and ensure resident safety.
Failure to Maintain Food Safety and Cleanliness in Kitchenettes
Penalty
Summary
The provider failed to adhere to necessary food safety guidelines in two kitchenettes located in the 100 and 200 hallways. Observations revealed that the exterior and interior of the refrigerators were unclean, with dried substances and unlabeled, undated food items such as vanilla frosting, bagels, sliced cheeses, salad dressings, and various sauces. The freezers contained unlabeled and undated pre-cooked pancakes and microwave bacon. Additionally, the water dispenser and ice machine were found with lime scale and slime buildup, and the kitchen surfaces and appliances, including the toaster, microwave, and stove, were unclean with dried food particles and grease. Interviews with staff, including the environmental services supervisor, director of nursing, and infection control nurse, highlighted a lack of awareness and responsibility for the cleanliness and maintenance of the kitchenettes. The dietary department, employed by the adjacent hospital, was responsible for cleaning and maintaining the kitchenettes, but failed to ensure food items were labeled and dated. The infection control nurse admitted to not auditing the kitchenettes for infection control standards, and the director of nursing was unaware of the cleaning chemicals accessible to residents. Further interviews with the cook and nutrition and food services supervisor revealed inconsistencies in cleaning practices and checklist completion. The cook admitted to cleaning the kitchen daily but only checking the fridge weekly, while the supervisor checked the kitchenettes twice a week but noted incomplete cleaning checklists. The provider's policies on equipment cleaning and leftover foods were not followed, as evidenced by the unclean kitchenettes and unlabeled food items. The lack of adherence to these policies contributed to the deficiency in maintaining a clean and safe food environment.
Failure to Report Elopement Incidents to Authorities
Penalty
Summary
The provider failed to notify the South Dakota Department of Health (SD DOH) of two elopement incidents involving a resident diagnosed with dementia and Alzheimer's disease. The resident, who had a Brief Interview of Mental Status (BIMS) score indicating an unsuccessful interview, eloped from the facility on three occasions. On the first occasion, the resident was found outside the facility after another resident alerted staff. On the second occasion, the resident was found walking outside but had not yet reached the parking lot. These incidents were not reported to the SD DOH as required. Interviews with the Director of Nursing (DON) and the Director of Nursing Trainer (DONT) revealed a lack of awareness and misinterpretation of the incidents as non-elopements. The DONT initially did not consider the incidents as elopements because they were witnessed by another resident or because the resident had not reached the parking lot. However, upon reviewing the nurse's progress notes, the DONT confirmed that these incidents should have been classified as elopements and reported accordingly. The facility's policy required incident reporting and care plan revisions following elopements, which were not adhered to in these cases.
Failure in Timely Skin Assessment and Physician Notification
Penalty
Summary
The provider failed to ensure timely skin assessments and notification to the physician for a resident identified at risk for developing skin injuries. The resident, who had a history of boils in the affected area, developed a wound on the left buttock. The wound was initially observed by a nursing supervisor and wound care nurse, who noted it was healing but had not been promptly assessed or reported to the physician when first identified. The resident's medical record indicated a care plan for impaired skin, but the interventions were not consistently followed. The CNA Skin Inspection Report showed discrepancies in documentation, with a sore identified on different dates and locations, but not consistently followed up by licensed nursing staff. The wound was not assessed by a nurse on a weekly basis as required, and there was a lack of documentation in the nurse's progress notes regarding the wound's status. Interviews with nursing staff revealed confusion and inconsistency in the skin assessment process. The wound care nurse admitted that the resident was not on a weekly assessment schedule, and the CNA's role in identifying skin concerns was misunderstood. The facility's policy on skin breakdown prevention was not effectively implemented, as deviations in skin assessment were not documented in the resident's clinical record, and a formal policy for assessing a resident's skin was not provided during the survey.
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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