Spearfish Canyon Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Spearfish, South Dakota.
- Location
- 1020 N 10th Street, Spearfish, South Dakota 57783
- CMS Provider Number
- 435043
- Inspections on file
- 23
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Spearfish Canyon Healthcare during CMS and state inspections, most recent first.
A CNA verbally abused a cognitively impaired resident with dementia and anxiety during morning walking rounds when the resident asked for assistance, responding with an expletive-laden statement and refusing help. Another CNA intervened by assisting the resident back to her room and directing the abusive CNA to leave. The involved CNA had prior training on abuse/neglect, residents' rights, and the facility's grievance policy, and maintained a current CNA certification with a clear background check, yet still engaged in this verbally abusive interaction, leading to a deficiency at F600.
The facility did not consistently monitor or document the low-temperature dishwasher's wash temperatures, resulting in multiple instances where the required minimum of 120°F was not met and numerous undocumented temperature checks. Staff, including the dietary supervisor and maintenance technician, were unaware of the ongoing issue, and the facility's policy for dishwasher sanitation was not followed.
Two residents experienced deficiencies in their environment: one was not consistently provided with preferred cloth towels for handwashing, despite requests, and another was subjected to loud, disruptive noise from bulk oxygen tanks outside his room, which aggravated his anxiety and disturbed his daily activities. Staff were largely unaware of the impact of these issues, and facility policies regarding clean linens and comfortable sound levels were not followed.
A resident on dialysis with a physician-ordered fluid restriction was found with multiple bottled waters and sodas in her room, and her daily fluid intake was not being tracked or calculated as required. Staff did not consistently remove excess fluids from her room, and the fluid restriction order was not added to the TAR, resulting in a failure to monitor and enforce the prescribed fluid limit.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment was not maintained to minimize risks, and supervision protocols were insufficient.
Expired influenza and pneumococcal vaccines were found in two medication room refrigerators, with staff interviews revealing confusion about who was responsible for checking and removing expired medications. Both nursing staff and the DON were unaware of the expired vaccines, despite facility policy requiring proper storage and disposal.
Surveyors identified infection control deficiencies when a CMA failed to clean an inhaler after use, a CNA did not change gloves or perform hand hygiene between cleaning urine and handling a catheter bag valve, and another CNA did not remind a resident to wash hands after bathroom use. Facility policies for glove use and resident hand hygiene were also lacking.
Two residents experienced preventable injuries when staff failed to follow established safety procedures: one resident suffered a burn from hot broth that was not prepared according to safe temperature protocols, and another resident fell and sustained skin tears when a CNA assisted her without using a gait belt as required by her care plan. Both incidents involved staff not adhering to facility policies designed to prevent accidents.
A resident on comfort care with a pending hospice referral and a urinary tract infection did not receive necessary repositioning and incontinence care during a night shift. The CNA responsible admitted to not providing the care, leading to the resident being found in a urine-saturated brief and linens, potentially increasing the risk of discomfort, infection, and skin breakdown.
A resident with cognitive impairment and tremors sustained a burn from spilling hot coffee. The investigation was incomplete, lacking witness statements and clear documentation. The provider's policies on incident investigation were not adequately followed, leading to the deficiency.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
Non-compliance at F600 occurred when a CNA verbally abused a resident during morning walking rounds. At approximately 6:30 a.m., two CNAs were conducting bedside handoff rounds on the 400 Hall when the resident exited her room and asked for assistance. In response, CNA D told the resident, "I don't have time for your [expletive word]." This interaction was witnessed by CNA C and other staff members nearby, who confirmed hearing the verbal exchange. CNA C then intervened by assisting the resident back into her room and directing CNA D to leave the facility. The resident involved had been admitted with diagnoses including dementia with behavioral disturbances and anxiety, and a BIMS score indicating moderately impaired cognition. At the time of the surveyor’s observation months later, the resident was asleep and unable to be interviewed. CNA D’s personnel file showed she had received education on abuse/neglect reporting, residents’ rights, and the facility’s grievance policy at hire, had signed understanding of the abuse policy, and had a current CNA certification and a clear background check. Despite this training and background, CNA D engaged in verbally abusive conduct toward the resident, resulting in the cited deficiency for failure to ensure the resident remained free from verbal abuse.
Failure to Consistently Monitor and Document Dishwasher Temperatures
Penalty
Summary
The facility failed to ensure that standard food safety practices were followed regarding the monitoring and documentation of the low-temperature dishwasher's wash temperature. Observations revealed that the dishwasher temperature logs for two consecutive months showed multiple instances where the recorded wash temperatures were below the required minimum of 120 degrees Fahrenheit, with thirty-six low readings in August and five in July. Additionally, there were numerous undocumented temperature checks, with forty-one missing entries out of ninety-three opportunities in July. Staff interviews confirmed that the dietary supervisor was unaware of the low temperature readings and had not checked the logs due to being preoccupied with training new staff. The dietary aide reported needing to run the dishwasher multiple times before reaching the required temperature, and the maintenance technician was not previously informed of the issue and had not performed recent maintenance on the dishwasher. The administrator was also unaware of the dishwasher's low wash temperature readings and expected kitchen staff to notify the dietary supervisor of any issues. The facility's policy required a minimum wash temperature of 120 degrees Fahrenheit for low-temperature dishwashers, but this standard was not consistently met or documented. There were no reports of gastrointestinal outbreaks at the time of the survey. The deficiency was identified through observation, record review, and staff interviews, which demonstrated a lack of consistent monitoring and documentation of dishwasher temperatures as required by facility policy.
Failure to Provide Homelike Environment Due to Noise and Linen Preferences
Penalty
Summary
The facility failed to ensure a homelike environment for two residents due to issues with noise levels and the availability of preferred linens. For one resident, staff did not consistently provide a clean washcloth and hand towel on the towel rack for use after handwashing, despite repeated requests from the resident and his spouse. The resident was able to use the handwashing sink independently and preferred cloth towels over paper towels, as was his custom at home. Observations confirmed that a used washcloth remained on the sink countertop for an extended period, and no clean cloth towels were provided, contrary to the facility's policy to maintain clean bed and bath linens. Another resident was exposed to loud, intermittent hissing noises from bulk oxygen tanks placed directly outside the wall of his room. The noise from the tanks' pressure release was significant enough to interrupt conversations, television viewing, and the resident's ability to listen to books on tape. The resident, who had a history of generalized anxiety disorder, PTSD, and other mental health conditions, reported that the noise startled him, increased his anxiety, and disturbed his sleep. Staff interviews revealed a lack of awareness regarding the impact of the noise on the resident, and the tanks had been in that location since before the resident's admission. The facility's policy defined a homelike environment as one with comfortable sound levels and the provision of clean linens. In both cases, the facility did not meet these standards, as the resident's preferences for linens were not accommodated and the noise from the oxygen tanks created an uncomfortable and disruptive environment.
Failure to Monitor and Enforce Fluid Restriction for Dialysis Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a process to ensure accurate accounting of daily fluid intake for a resident on dialysis with a physician-ordered fluid restriction. The resident had a documented order limiting fluid intake to 1500 cc per day, with specific allocations for dietary and medication administration. During observation, the resident was found with multiple bottled waters, a six-pack of soda, and a lidded cup of water in her room, and was seen drinking from one of the bottles. The resident confirmed she had been advised by her medical provider to limit fluid intake. Staff interviews revealed that while the resident was listed as having a fluid restriction in the huddle book, excess fluids were not consistently removed from her room, particularly after returning from dialysis when unused bottled water was brought back and left in her room. Further review showed that the resident's fluid restriction order had not been added to her treatment administration record (TAR), and her daily fluid intake was not being calculated or monitored as required. The facility's policy stated that fluid intake should be recorded on the medication record and that water should not be provided at the bedside unless included in the daily restriction or specifically ordered. The director of nursing acknowledged that the facility's processes for tracking and limiting the resident's fluid intake were not followed, and unnecessary fluids were not removed from the resident's room.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Expired Vaccines Found in Medication Refrigerators
Penalty
Summary
Surveyors observed that two medication room refrigerators contained expired vaccines, including influenza and pneumococcal 13-valent vaccines. Specifically, ten expired influenza vaccines and one expired pneumococcal vaccine were found in one refrigerator, while three expired influenza vaccines and one expired pneumococcal vaccine were found in another. Staff interviews revealed confusion and lack of clarity regarding responsibility for checking and removing expired vaccines. One RN believed night staff were responsible, while an LPN thought the pharmacist checked for expired medications monthly and was unaware of the expired vaccines' presence. The DON was also unaware of the expired vaccines and stated that the consultant pharmacist was expected to check for expired medications monthly, but all staff administering vaccines should have checked expiration dates. Facility policy required staff to store, administer, and discard pharmaceuticals according to procedures, including sending expired medications for destruction. Despite these policies, expired vaccines remained accessible in the medication refrigerators, available for administration to residents.
Infection Control Lapses in Medication Administration, Catheter Care, and Resident Hand Hygiene
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff. A certified medication aide (CMA) administered medication to a resident using an inhaler and returned the uncleaned inhaler to its box in the medication cart, despite acknowledging that the mouthpiece should have been cleaned with an alcohol pad after use. The inhaler was stored with other residents' medications, increasing the risk of cross-contamination. Additionally, a certified nurse aide (CNA) was observed cleaning urine from the floor and then, without changing gloves or performing hand hygiene, adjusted a resident's urinary catheter bag valve before resuming cleaning. The CNA admitted uncertainty about when to change gloves and perform hand hygiene, and agreed that his actions increased the resident's risk of infection. Another CNA assisted a resident after bathroom use but did not remind or assist the resident to perform hand hygiene, even though the resident was capable of independently washing his hands but did not always remember to do so. The CNA acknowledged the importance of resident hand hygiene after bathroom use. The facility's policies on metered-dose inhaler administration and hand hygiene were reviewed and found to require cleaning and hand hygiene in the situations observed, but there were no facility policies for glove use or resident hand hygiene.
Failure to Prevent Accidents Due to Unsafe Hot Liquid Handling and Omission of Gait Belt Use
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for two residents. In one incident, a resident sustained a burn injury to her right leg after spilling hot broth that had been improperly prepared by a new cook who did not follow the facility's established procedures for safe food preparation and service. The cook used water from a stovetop kettle instead of the coffee machine, which is calibrated to maintain a safer temperature, and did not check the temperature of the broth before it was delivered to the resident's room. The resident, who had a history of left hip fracture, transient ischemic attack, macular degeneration, and tremor, was found with redness and later a blistered area on her right thigh after the spill. In a separate incident, another resident fell while being assisted back from the bathroom by a CNA who failed to use a gait belt, contrary to the resident's care plan and facility policy. The resident, who had a history of osteoporosis, multiple lumbar compression fractures, and moderate cognitive impairment, was identified as being at risk for falls and required assistance with transfers and ambulation using a front-wheeled walker and a gait belt. During the incident, the CNA applied the resident's TLSO brace but did not use a gait belt, and the resident was guided to the floor after reporting weakness in her knees. The resident sustained skin tears during the assisted fall. Both incidents involved staff not adhering to established facility policies and procedures designed to prevent accidents and injuries. The first incident resulted from a failure to follow safe food handling protocols for hot liquids, while the second incident was due to the omission of a required safety device during resident transfer. These actions directly contributed to the residents' injuries and represented a failure to maintain a safe environment as required by facility policy.
Failure to Provide Repositioning and Incontinence Care
Penalty
Summary
The provider failed to ensure that a resident's repositioning and incontinence care needs were met according to her plan of care. At the time of the incident, the resident was on comfort care with a pending hospice referral, incontinent of urine, and unable to reposition herself without staff assistance. She also had a urinary tract infection with pending lab results and anticipated antibiotic treatment orders. On the morning of the incident, a bath aide found the resident lying in bed with a urine-saturated incontinence brief and linens. The certified nursing assistant responsible for the resident's care admitted during the investigation that he had not provided the necessary repositioning or incontinence care during his night shift. This lack of care potentially placed the resident at a higher risk for discomfort, infection, and skin breakdown. The incident was identified during a facility-reported incident review by the South Dakota Department of Health, which included observations, interviews, and record reviews.
Failure to Conduct Thorough Investigation of Resident's Burn Incident
Penalty
Summary
The provider failed to ensure a thorough investigation was completed for a resident who sustained a burn from spilling hot coffee. The incident occurred when the resident, who had cognitive impairment and tremors, spilled coffee on her lap during breakfast. A CNA alerted an LPN, who assessed the resident and noted redness and blisters on her thigh. However, the investigation lacked statements from individuals who may have had knowledge of the event, and there was confusion about who initially reported the incident. The resident's medical record indicated she was not at risk for spilling hot liquids, but a subsequent evaluation revealed she had cognitive impairment and tremors, necessitating the use of a cup with a lid and drinking hot liquids at a table only. Interviews with the DON, LPN, and CNA revealed inconsistencies and gaps in the investigation process. The CNA could not recall who informed her of the spill, and the LPN was unsure about the identity of the CNA who reported the incident. The provider's policies on abuse, neglect, and incident investigation were not adequately followed, as the investigation did not include comprehensive documentation or witness statements. The lack of a thorough investigation and clear documentation led to the deficiency noted in the report.
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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