Avantara Arrowhead
Inspection history, citations, penalties and survey trends for this long-term care facility in Rapid City, South Dakota.
- Location
- 2500 Arrowhead Dr, Rapid City, South Dakota 57702
- CMS Provider Number
- 435051
- Inspections on file
- 25
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Avantara Arrowhead during CMS and state inspections, most recent first.
Two RNs failed to report allegations of suspected abuse after two residents with cognitive impairment reported being handled roughly by agency CNAs, resulting in pain and minor injuries. The nurses either addressed the issue directly with the CNA or documented it in progress notes but did not escalate the allegations to management as required.
A deficiency was identified when a CNA failed to provide care in pairs as required for a resident with cognitive and psychosocial needs, and another CNA did not use the required mechanical lift for a resident with severe cognitive impairment, resulting in a fall. Both incidents involved staff not following clearly documented care plans and care sheets.
A resident with a recent neck fracture and chronic pain did not receive timely or adequate pain management due to delays in medication delivery, staff communication issues, and inconsistent responses to pain complaints. The resident experienced significant discomfort, reported long wait times for assistance, and ultimately left the facility against medical advice after expressing dissatisfaction with care.
Three residents experienced falls due to staff not following safety protocols for equipment use, including failure to secure safety belts and lock wheels on bath chairs and mechanical lifts. In one case, a resident suffered cervical fractures after falling from an unsecured bath chair, and staff did not complete required neurological assessments. Other incidents involved residents falling during transfers when safety straps were not used, despite staff being aware of these requirements. Care plans were not updated after these events, and facility policies for safe equipment operation were not consistently followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
The facility did not ensure that a resident received proper care for existing pressure ulcers and failed to implement adequate preventive measures to stop new ulcers from developing.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
Multiple residents using oxygen and CPAP equipment did not have their respiratory devices cleaned, replaced, or stored according to facility policy and manufacturer instructions. Observations showed dusty concentrators, undated and improperly stored nasal cannulas, and missing documentation for scheduled cleaning and replacement. Staff interviews revealed confusion about responsibilities, and facility records confirmed inconsistent scheduling and documentation of required maintenance tasks.
An LPN administered an incorrect dose of diclofenac sodium gel by failing to use the manufacturer's dosing card and also crushed and administered a delayed-release omeprazole tablet to a resident, despite facility policy and manufacturer instructions prohibiting this. These actions resulted in a medication error rate of 6.9%.
Surveyors found that kitchen staff did not follow proper hand hygiene procedures, specifically failing to use a paper towel to turn off the faucet after washing hands, as required by facility policy. The kitchen and food storage areas were not maintained in a clean condition, with dust and buildup observed on equipment and surfaces. Additionally, food items in the dining room refrigerator were improperly labeled and stored, with some items undated, spoiled, or moldy, and not discarded as required by policy.
Staff did not consistently follow infection control protocols, including failure to wear required PPE when entering rooms under Enhanced Droplet Precautions, inadequate hand hygiene practices after glove removal and before resident care, and improper cleaning and disinfection of a shared glucometer used for multiple residents. Facility policy requiring individual, labeled glucometers for each resident was not followed, and staff did not have necessary cleaning supplies readily available.
A resident's advance directive wishes were not accurately identified or documented after returning from a hospital stay, resulting in conflicting code status information between the EMR and paper chart. The EMR was updated to 'Intubate Only' without discussion with the resident, despite signed DNR documents and a care plan indicating DNR status. Staff confirmed they would follow the highest level of care listed, which did not reflect the resident's wishes.
An LPN left a resident's EMR information visible and unsecured on a medication cart computer while away administering medications, allowing staff and residents to pass by and view the protected health information. The DON confirmed that the system has a lock screen feature and staff are expected to use it, in accordance with the facility's HIPAA policy.
A resident with multiple mental health diagnoses, including PTSD, was admitted with an inaccurate Level 1 PASRR that failed to identify their mental illness, resulting in the lack of evaluation for specialized mental health care needs. The resident did not receive services for PTSD, and facility staff acknowledged the PASRR was completed incorrectly.
Two residents with intact cognition and complex psychiatric histories, including PTSD and depression, did not have their care plans reviewed or revised to address trauma exposure and related needs. Their care plans lacked individualized interventions for trauma triggers, coping mechanisms, and specific behavioral symptoms, despite facility policy requiring person-centered care planning. Staff interviews confirmed reliance on care plans for guidance, but trauma-informed care was not addressed for these residents.
Two residents with PTSD and histories of trauma did not receive individualized, trauma-informed care planning or interventions. Their care plans lacked specific strategies to address their mental health needs, triggers, or behaviors, and trauma assessments were incomplete or inaccurate. Staff confirmed that trauma-informed care was not incorporated as required by facility policy.
A resident did not receive the medically-related social services needed to help achieve the highest possible quality of life, as required by regulations.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A CNA handled a resident roughly during morning care, resulting in injuries and pain, while another resident with cognitive impairment made unsolicited sexual contact with a female resident after missing scheduled Depo-Provera injections. Both incidents involved failures to protect residents from abuse, as identified through staff observations, resident reports, and record reviews.
Two residents experienced significant medication errors when staff failed to administer physician-ordered medications due to missing or unavailable doses, despite some medications being present in the E-Kit. Staff did not consistently check all available sources for medications, and the facility did not complete required medication error reports for all missed doses, as confirmed by the DON. The medication reordering and communication processes were not reliably followed, leading to repeated missed doses and incomplete documentation.
A resident with multiple complex medical conditions did not receive several scheduled Depo-Provera injections due to medication unavailability, and there was no documentation that the physician was notified of these missed doses as required by facility policy. The DON confirmed the lack of physician notification for the missed doses, and medication error reports were not completed for all instances.
Two CNAs failed to provide timely incontinence care to two residents with continence assistance needs, resulting in both individuals remaining in soiled briefs until the night shift. One resident, with paraplegia and other medical conditions, was left unattended after multiple requests for help, while another, with moderate cognitive impairment and ataxic cerebral palsy, was found soaked in urine. These actions were confirmed through staff interviews and record review, and the incidents were reported as neglect.
A resident with severe cognitive impairment and multiple health conditions developed a skin rash with scabbing and abrasions, but did not receive scheduled bathing for extended periods and experienced delays in receiving physician-ordered topical treatment. Staff interviews revealed uncertainty about the bathing schedule and documentation lapses, while medical records showed delayed initiation of appropriate skin care interventions.
A resident with significant medical comorbidities and high risk for pressure ulcers developed a new skin injury that was observed by a CNA and reported to nursing staff. However, the responsible RN did not assess or document the injury, notify the physician, or initiate treatment, and subsequent staff also failed to follow proper procedures for assessment and care. This resulted in delayed intervention and a failure to follow the facility's protocol for new skin injuries.
A CNA observed a new skin injury on a resident and reported it to the RN and wound care nurse. The RN did not assess or document the injury, nor notify the physician or obtain treatment orders. The CNA, acting outside their scope of practice, independently applied a dressing to the injury without direction from the RN.
A resident with multiple comorbidities and a full code status was found unresponsive and cold by staff. The RN and LPN did not assess for irreversible signs of death or promptly initiate CPR, and there was a delay in identifying the resident's code status and calling 911. Documentation of the resident's change in condition was also lacking, resulting in a deficiency related to failure to provide basic life support as required.
A resident with moderate cognitive impairment and a history of wandering and falls was allowed outside without required supervision, contrary to their care plan. The resident fell while unsupervised, resulting in injuries and a trip to the ED. Staff interviews confirmed that supervision was necessary, but it was not provided at the time of the incident.
A resident with multiple health conditions suffered a skin tear on her leg, which continued to bleed over several days. Despite repeated dressing changes by staff, the facility lacked adequate supplies, and the decision was made not to send the resident to the emergency department. The resident's condition worsened, and she passed away shortly after. The facility's neglect and wound care policies were not effectively followed, leading to inadequate care.
A resident at high risk for pressure injuries was admitted with only heel lift boots as an intervention. Despite a care plan requiring repositioning every two hours, this was not consistently done, leading to a pressure injury. Staff interviews revealed communication and documentation gaps, and weekly skin assessments were not completed as required.
The provider failed to monitor a bowel management program for a resident with ataxic cerebral palsy who experienced significant weight loss and frequent diarrhea. Despite the resident's reports and documentation of multiple loose stools, the physician and dietitian were not notified, and the resident continued to receive laxatives and stool softeners. Staff interviews revealed a lack of communication and awareness regarding the resident's condition, contributing to the deficiency.
The facility failed to ensure proper medication administration and documentation. An RN left nutritional supplements and Mirilax on a table without ensuring consumption, leading to inaccurate MAR documentation. An LPN administered lorazepam and morphine but did not document it. Additionally, tube feeding and water flushes for a resident with a feeding tube were not accurately documented.
The provider failed to ensure medications were administered as ordered for two residents. One resident received incorrect doses of clonazepam on multiple occasions, and another resident was given lisinopril without the required blood pressure check. These errors were not reported or investigated as per facility policy.
The provider failed to ensure accurate labeling of prescription medications for two residents and allowed a CMA to alter a medication label. Resident 14's MAR indicated a daily dose of clonazepam, but the blister pack label stated 'as needed,' which the CMA altered with a marker. For Resident 32, the RN administered lisinopril without following the hold instruction on the blister pack label, which was not present on the MAR. The DON confirmed that staff should reconcile discrepancies before administering medications.
The provider failed to ensure proper infection control practices by an OT and an ADON. The OT did not perform hand hygiene or change gloves after assisting a resident, and the ADON improperly handled the faucet during hand washing. Both staff members confirmed their lapses in following infection control protocols.
Failure to Timely Report Allegations of Suspected Abuse by Nursing Staff
Penalty
Summary
Two registered nurses failed to report allegations of suspected abuse involving two residents. In the first case, a resident with Parkinson's disease, spinal stenosis, and moderate cognitive impairment reported to a nurse that an agency CNA had handled him roughly during care, resulting in pain and minor injuries. The nurse spoke to the CNA and instructed her to be more careful but did not report the allegation to management as required. The resident had visible bruising and scabbing, some of which was attributed to the use of a sit/stand lift and scratching due to dry skin. In the second case, another resident with Alzheimer's disease, dementia, and moderate cognitive impairment told an agency CNA that she was being rough during incontinent care, causing pain due to arthritis in her shoulders. The CNA slowed down after being told, but did not offer pain medication or inquire further. The CNA reported the resident's statement to a nurse, who checked on the resident later and documented the incident in the progress notes but did not recognize it as an allegation of abuse requiring immediate reporting to management. Both incidents were later discovered by facility management during reviews of resident complaints and progress notes. The failure to report these allegations of suspected abuse by the nurses constituted non-compliance with regulatory requirements for timely reporting and investigation of abuse allegations.
Failure to Follow Care Plans for Supervision and Transfer Leading to Deficiencies
Penalty
Summary
A deficiency occurred when an agency CNA failed to follow a resident's care plan requiring 'cares in pairs' for a resident with ataxic cerebral palsy, delusional disorder, major depressive disorder, and epilepsy. The resident, who was cognitively intact, had a care plan and care sheet indicating that two staff members were required to be present during care due to a history of embellishing or fabricating stories. Despite this, the agency CNA provided care alone, which led to an allegation of inappropriate touching. The resident's care plan was clearly marked, and the CNA had received training on the 'cares in pairs' procedure prior to the incident. Another deficiency was identified when a CNA did not follow the care plan for a resident with traumatic subarachnoid hemorrhage, insomnia, dysphagia, depression, hypertension, and repeated falls. The resident, who was severely cognitively impaired, required a total body mechanical lift with two staff members for all transfers, as documented in both the care plan and care sheet. The CNA transferred the resident using a gait belt instead, resulting in a fall. The CNA had previously sought clarification from therapy staff but misunderstood the instructions, and the care plan had not changed. Both incidents involved staff not adhering to the individualized care plans and care sheets, which were clearly documented and communicated. In both cases, the staff involved had current certifications, completed required trainings, and had no background check concerns. The deficiencies were identified through interviews, record reviews, and facility-reported incidents.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with a recent C2 vertebra fracture, chronic pain syndrome, depression, anxiety disorder, and insomnia was admitted to the facility and consistently reported unmanaged pain and lack of staff response to requests for pain medication. The resident experienced long call light wait times and voiced concerns that staff, particularly an LPN, were not assisting with her needs. Documentation shows that the resident was in significant pain, as evidenced by pain scores of 10, and was heard yelling in discomfort when repositioned. The resident did not receive her prescribed acetaminophen on the first day and had to wait for narcotic pain medication due to delays in prescription processing and pharmacy communication issues. Staff interactions with the resident were marked by escalating behaviors and verbal altercations. The LPN instructed CNAs to provide care in pairs due to the resident's behaviors and eventually advised staff to avoid the resident for their own safety, following continued threats and verbal abuse from the resident. The LPN was later suspended for inaccurate and subjective charting and for instructing staff to stop providing care to the resident. During this period, the resident continued to express pain and dissatisfaction with the care provided, ultimately deciding to leave the facility against medical advice. The facility's medication administration records confirmed that the resident did not receive all prescribed pain medications in a timely manner. Delays were attributed to prescription errors and issues with the medication dispensing system. Interviews with staff and review of progress notes indicated that the resident's pain was not adequately managed during her short stay, and staff responses to her needs were inconsistent and, at times, insufficient.
Failure to Prevent Accidents Due to Improper Equipment Use and Inadequate Supervision
Penalty
Summary
Staff failed to ensure the safety of three residents who experienced falls related to improper use of equipment. In one instance, a certified nurse aide (CNA) did not secure a safety belt on a bath chair while a resident was seated, resulting in the resident falling forward onto the floor after being moved out of the whirlpool bathtub. The resident sustained a head laceration, nosebleed, and was later found to have cervical fractures. The CNA involved had previously signed an education sheet confirming receipt of training on proper equipment use, including securing safety belts, just three days prior to the incident. However, the CNA stated she was unaware of the requirement to use the seat belt. Following the fall, there were discrepancies in the accounts provided by the registered nurses (RNs) who responded to the incident, and it was unclear whether the resident was appropriately repositioned. The resident was moved with a Hoyer lift to a wheelchair before emergency medical services arrived, despite facility policy indicating that residents with suspected major injuries should not be moved. Additionally, there was no documented neurological evaluation completed after the fall, contrary to facility policy requiring such assessments for falls involving head trauma. In two other incidents, staff failed to use required safety straps during transfers with mechanical lifts. One resident fell from a sit-to-stand lift when the leg straps were not used, resulting in pain and hospital evaluation. Another resident fell from a bath chair after the seatbelt was removed and not replaced, and the chair's wheels were not locked. In both cases, staff were aware of the safety requirements but did not follow them. Care plans were not updated following these incidents as expected. Facility policies and manufacturer instructions required the use of safety belts and locking of wheels during equipment use, but these were not consistently followed.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Failure to Clean and Store Respiratory Equipment per Policy
Penalty
Summary
The facility failed to ensure that respiratory treatment equipment, including oxygen concentrators, nasal cannulas, and CPAP machines, was cleaned and stored according to manufacturer instructions and facility policy for multiple residents. Observations revealed that several oxygen concentrators had visible dust and debris on their filters and exteriors, with one concentrator labeled with another person's name. Nasal cannulas were found undated, improperly stored—such as hanging over wheelchair wheels or lying on the floor—and in some cases, not replaced according to the facility's weekly schedule. Documentation in the treatment administration records (TAR) was inconsistent or missing for scheduled cleaning and replacement tasks. Residents using oxygen and CPAP equipment had varying degrees of cognitive function and medical needs, including chronic respiratory failure, hypoxia, and sleep apnea. Interviews with residents indicated a lack of awareness regarding the maintenance of their respiratory equipment. For example, one resident with severe cognitive impairment could not confirm if his CPAP mask and tubing or oxygen concentrator were cleaned, while another resident with intact cognition was unaware of any replacement or cleaning of her equipment. The CPAP mask and tubing for one resident were left assembled and not cleaned or scheduled for cleaning as required. Staff interviews revealed confusion and inconsistency regarding responsibilities for cleaning and maintaining respiratory equipment. Certified medication aides and LPNs provided differing accounts of who was responsible for cleaning concentrator filters, with some believing it was a nursing duty and others attributing it to maintenance or an outside oxygen company. The infection preventionist and DON confirmed that cleaning and replacement tasks were to be documented in the TAR, but acknowledged that documentation was missing or not scheduled for some residents. Facility policies required weekly cleaning and replacement of equipment, proper storage of nasal cannulas, and documentation of these tasks, but these procedures were not consistently followed.
Medication Error Rate Exceeds 5% Due to Improper Administration and Crushing of Medications
Penalty
Summary
A medication error rate of 6.9% was identified during observation of medication administration by an LPN. The LPN dispensed an unknown amount of diclofenac sodium 1% gel for a resident's arthritis pain and inflammation, failing to use the manufacturer's enclosed dosing card as required. The LPN was unaware of the measuring device included in the medication packaging and could not confirm the correct dose, resulting in improper administration. The medication administration record (MAR) specified a two-gram dose, but the LPN guessed the amount and only discovered the dosing card after the error was pointed out. Additionally, the same LPN crushed and administered an extended-release medication, omeprazole 20mg delayed-release oral tablet, to another resident who required medications to be crushed. The MAR did not indicate that these medications should be crushed, and the LPN was unaware that omeprazole was a delayed-release formulation, only realizing the error after reviewing the medication label. The facility's policy and the manufacturer's recommendations both specify that extended-release or delayed-release medications should not be crushed and that medications must be administered as prescribed and in accordance with manufacturer specifications.
Failure to Follow Food Safety and Hand Hygiene Protocols
Penalty
Summary
Surveyors observed multiple failures to follow standard food safety and hand hygiene practices in the facility's kitchen and dining areas. Three of five kitchen staff, including a cook and two dietary aides, did not use a paper towel to turn off the faucet after handwashing, contrary to posted instructions and facility policy. This improper handwashing technique was observed during six of nine handwashing events. The dietary manager and infection preventionist confirmed that the policy requires using a paper towel to turn off the faucet to prevent recontamination. Additionally, the kitchen environment was not maintained in a clean condition, with a dusty power cord hanging above clean dishware, uncovered serving utensils, and dust and buildup on ventilation filters and air vents near food preparation and dishwashing areas. In the dining room refrigerator, food items belonging to three residents were found improperly stored. Several containers were labeled with resident names but lacked dates, and one container emitted a foul odor when opened. Another bag of vegetables was visibly moldy and undated. The activities director, responsible for managing the refrigerator, acknowledged that food without dates should have been discarded during the last cleaning, as per facility policy, which requires all food brought in from outside to be labeled with the date and discarded after three to five days. The cleaning log indicated the refrigerator had not been deep cleaned since the previous week, and undated or expired food was not removed as required.
Infection Control Failures in PPE Use, Hand Hygiene, and Glucometer Disinfection
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several observed instances. A guest services aide entered two residents' rooms, both under Enhanced Droplet Precautions, without donning the required personal protective equipment (PPE) such as gown, gloves, and eye protection, as indicated by signage. The aide only wore a face mask and did not change it between rooms, although she performed hand hygiene upon exiting each room. The aide acknowledged that PPE was expected in these rooms. A certified nurse aide (CNA) was observed removing unclean gloves after providing personal care to a resident and then immediately putting on a new pair of gloves without performing hand hygiene in between. The CNA confirmed that hand hygiene should have been performed after glove removal and before donning new gloves. Additionally, an LPN was seen placing a straw into a resident's water cup with bare, unwashed hands, and admitted that she should have either washed her hands or worn gloves before handling the straw. There was also a failure to follow manufacturer and facility policy regarding the cleaning and disinfection of a shared blood glucose monitor (glucometer). An LPN used an unlabeled glucometer for multiple residents, did not have cleaning wipes readily available, and did not follow the manufacturer's instructions for cleaning and disinfecting the device between uses. The facility's policy required individual glucometers for each resident, properly labeled and stored, but this was not followed, as confirmed by the Director of Nursing.
Failure to Accurately Document and Confirm Advance Directive After Hospitalization
Penalty
Summary
A deficiency occurred when a resident's advance directive wishes were not accurately identified and documented after returning from a hospital stay. The resident's electronic medical record (EMR) listed his code status as 'Intubate Only,' while two signed Do Not Resuscitate (DNR) documents were present in both his EMR and paper chart, each signed by the resident, a provider, and a facility agent. The resident's care plan also indicated DNR status, and during an interview, the resident confirmed he believed his code status was DNR and expressed that he did not want to be intubated again after a previous experience. A licensed practical nurse (LPN) confirmed the discrepancy between the paper chart (DNR) and the EMR (Intubate Only), stating she would follow the highest level of care listed, which was 'Intubate Only.' The nurse supervisor updated the EMR to 'Intubate Only' after the resident returned from the hospital, based on a change observed during the hospital stay, but did not discuss this change with the resident. The director of nursing (DON) stated that any code status change after hospitalization should be confirmed with the resident, and that code status is reviewed at care conferences. The failure to confirm and accurately document the resident's code status led to the deficiency.
Failure to Secure Resident PHI on Unattended EMR Screen
Penalty
Summary
A licensed practical nurse (LPN) failed to secure a resident's protected health information (PHI) by leaving the electronic medical record (EMR) screen unlocked and visible on the medication cart while administering medications in the west hall. During this time, multiple staff members and residents walked past the unlocked screen, which displayed the resident's EMR information. The LPN acknowledged that the computer screen should have been locked when unattended. The director of nursing (DON) confirmed that the facility's EMR system includes a lock screen feature and that staff are expected to use it whenever they step away from the computer. Review of the facility's HIPAA policy further emphasized the requirement to log off computers when not in use and to protect PHI from unauthorized access. The incident constituted a breach of the facility's policy and federal HIPAA regulations regarding the privacy and security of resident information.
Failure to Complete Accurate PASRR for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a diagnosed mental disorder, specifically post-traumatic stress disorder (PTSD), had an accurate Preadmission Screening and Resident Review (PASRR) completed. The resident, who had a history of alcohol abuse, major depressive disorder, anxiety disorder, PTSD, depression, adjustment disorder, and hallucinations, was admitted with a Level 1 PASRR that incorrectly indicated no evidence of mental illness. The care plan identified risks related to altered thought processes, and the resident's medical record documented multiple mental health diagnoses. Despite these documented conditions, the PASRR screening did not reflect the presence of a mental disorder, and the resident was not evaluated for specialized mental health care needs as required. During interviews, the resident reported not receiving any services for PTSD since admission and was unaware of any such offerings. The social services designee acknowledged that the PASRR was completed incorrectly and agreed that a Level II PASRR would have been appropriate. The facility's policy requires accurate identification and evaluation of residents with serious mental illness or intellectual disabilities, but this process was not followed, resulting in the failure to identify and address the resident's mental health care needs.
Failure to Individualize Care Plans for Residents with Trauma and Mental Health Needs
Penalty
Summary
The facility failed to review and revise the care plans for two residents with trauma exposure and related mental health needs, as required by their own policies and federal regulations. Both residents had intact cognition and complex psychiatric histories, including diagnoses such as PTSD, depression, anxiety, and adjustment disorder. Despite these diagnoses and documented symptoms, their care plans lacked individualized interventions addressing their trauma triggers, coping mechanisms, and specific behavioral symptoms. For example, one resident reported not being offered any PTSD-related services and was unaware of any trauma-informed interventions in place, while the other resident had not discussed her past traumas with staff and did not recall being offered counseling services since admission. Care plan reviews revealed that interventions were generic and did not specify what would trigger the residents' PTSD, how staff should respond to trauma-related behaviors, or what specific actions should be taken during episodes of altered thought processes or hallucinations. The care plans also failed to address the residents' emotional and psychosocial needs in a person-centered manner, omitting details about their personal histories, trauma experiences, and preferred coping strategies. This lack of specificity meant that staff did not have clear guidance on how to support these residents in managing their mental health conditions. Interviews with staff, including CNAs, LPNs, and the DON, confirmed that care plans are relied upon to guide resident care, especially for unfamiliar residents. The DON acknowledged that trauma-informed care was not addressed in the care plans for these residents and that such information should be included to ensure appropriate care. The facility's policies require individualized, resident-centered care planning that incorporates personal history and trauma exposure, but these requirements were not met for the two residents in question.
Failure to Provide Trauma-Informed and Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to implement trauma-informed and culturally competent care approaches for two residents with diagnosed post-traumatic stress disorder (PTSD) and histories of trauma. Both residents, who were veterans, had intact cognition and multiple mental health diagnoses, including PTSD, depression, and anxiety. Despite these diagnoses, neither resident had individualized care plan interventions that addressed their trauma histories, potential triggers, or specific behavioral symptoms related to PTSD. One resident reported not having discussed her past traumas with staff and did not recall being offered counseling services since admission, while the other resident was unaware that the facility recognized his PTSD diagnosis and had not been offered related services. Review of the residents' electronic medical records and care plans revealed that the interventions listed were generic and did not include trauma-specific strategies, identification of triggers, or guidance for staff on monitoring and responding to PTSD-related behaviors. The care plans lacked person-centered approaches tailored to the residents' unique trauma experiences, as required by facility policy. Additionally, the trauma screening and social services assessments were incomplete or inaccurately documented, with key questions about trauma history and mental health diagnoses marked as "No" despite clear evidence to the contrary in the residents' medical records. Interviews with facility staff, including the social services designee and the director of nursing, confirmed that trauma-informed care was not addressed in the care plans for these residents. Staff acknowledged that information gathered during trauma assessments should be included in care plans to prevent re-traumatization and to guide individualized care. The facility's own policy emphasized the need for person-centered care planning and consistent implementation of care approaches for residents with trauma histories, but these requirements were not met for the two residents in question.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to meet their individual needs.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
A certified nursing assistant (CNA) failed to protect a resident from potential physical abuse during morning care. The resident, who was cognitively intact and had a history of Parkinson's disease, hypertension, spinal stenosis, and falls, reported to multiple staff members that the CNA was upset with him and handled him roughly. The resident sustained an ankle injury and abrasions on both shins during the transfer from bed to wheelchair, and required both scheduled and PRN pain medication for his ankle pain. Staff observed the resident's distress and documented new skin injuries following the incident. In a separate incident, a resident with moderate cognitive impairment and a history of traumatic brain injury, dementia, and psychiatric conditions made unsolicited sexual advances toward another resident. The event was witnessed by a registered nurse, who observed the resident placing his hand inside the shirt of a female resident. Video footage confirmed the inappropriate contact, which lasted approximately twenty seconds before staff intervened. The resident's medication review revealed that his scheduled Depo-Provera injections, intended to help control sexually inappropriate behaviors, had not been administered for two consecutive months due to medication unavailability and scheduling issues. Both incidents involved failures to protect residents from abuse—physical in the first case and sexual in the second. In each case, the deficiencies were identified through resident reports, staff observations, and review of medical and facility records. The events highlighted lapses in staff conduct and medication administration that directly led to residents being exposed to abuse or potential abuse.
Failure to Administer Medications as Ordered Due to Unavailable Medication and Incomplete Error Reporting
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents, resulting in significant medication errors. For one resident with a diagnosis of radiculopathy, a 30-day supply of Gabapentin was delivered, but 49 capsules went missing and the facility could not determine when or how they disappeared. As a result, the resident missed multiple scheduled doses of Gabapentin over several days. Although Gabapentin was available in the facility’s Emergency Kit (E-Kit), nursing staff and a qualified medication aide did not check the E-Kit and assumed the medication was unavailable, leading to further missed doses. Documentation confirmed that the pharmacy had delivered replacement Gabapentin to the E-Kit, but staff failed to utilize it, and the missed administrations were acknowledged as medication errors by the Director of Nursing (DON). Another resident, who had a history of traumatic brain injury, cognitive impairment, and other complex medical conditions, did not receive ordered monthly Depo-Provera injections on several occasions because the medication was not available. Progress notes indicated repeated instances where the medication was not available and orders were sent to the pharmacy, but there was no documentation of administration for multiple months. Medication error reports were completed for some missed doses, but not for all, and the DON confirmed that the facility did not follow its own policy for documenting and reporting all medication errors related to these missed injections. Interviews with staff revealed that the medication reordering process relied on reminders and manual reordering through the electronic medical record system, but lapses in communication and follow-through led to medication shortages and missed doses. The DON reviewed progress notes daily but did not identify all missed doses or ensure that medication error reports were completed as required by facility policy. The facility’s policy required documentation, investigation, and reporting of all medication errors, but these procedures were not consistently followed, resulting in unaddressed medication errors for both residents.
Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident did not receive prescribed Depo-Provera injections as ordered. Documentation revealed that the resident, who had a history of traumatic brain injury, dementia, depressive disorder, seizures, and other significant medical conditions, missed several scheduled doses of Depo-Provera over multiple months due to the medication not being available. Progress notes indicated that the medication was ordered from the pharmacy when unavailable, but there was no documentation that the physician was notified of missed doses on three specific occasions. Additionally, the facility's own policy required physician notification whenever an order was not followed for any reason, including medication unavailability. The director of nursing confirmed that there was no documentation of physician notification for the missed doses on the identified dates. Medication error reports were only completed for two of the missed doses, with physician notification documented for those instances, but not for the earlier missed doses.
Failure to Provide Prompt Incontinence Care Constitutes Neglect
Penalty
Summary
Two certified nursing assistants (CNAs) failed to provide prompt incontinence care to two residents who required assistance with continence. One resident, who was cognitively intact and had a history of paraplegia, pneumonia, and chronic obstructive pulmonary disease, reported that a CNA did not return to provide incontinence care after being called twice during the day shift. The resident remained in a soiled brief until the night shift CNA provided care. Skin assessments prior to the incident noted redness and inflammation in the groin area, but no further skin issues were documented after the incident. Another resident, who had moderate cognitive impairment and diagnoses including ataxic cerebral palsy, muscle weakness, depressive disorder, and epilepsy, was found by a night shift CNA to be soaked in urine. The resident stated that the day shift CNA had not changed her brief. A skin assessment completed prior to the incident noted an impression on the right upper buttock but no redness or open areas. No additional skin issues were documented following the incident. Interviews with facility staff confirmed that the two CNAs responsible for day shift care did not provide timely incontinence care to the residents. The incidents were reported as neglect by the facility, and the staff involved were identified through schedule review and interviews. The failure to provide prompt incontinence care constituted neglect and resulted in a deficiency finding.
Failure to Provide Scheduled Bathing and Timely Skin Rash Treatment
Penalty
Summary
A severely cognitively impaired resident with multiple comorbidities, including sepsis, UTI, COPD, depression, dementia, and diabetes, was admitted to the facility and developed a skin rash characterized by scabbing and abrasions on various parts of the body. Documentation revealed that the resident did not receive any baths from admission through the end of the first month, received only four baths the following month with a two-week gap, and had only one bath before discharge in the final month. Staff interviews confirmed uncertainty regarding the lack of scheduled bathing, with one CNA noting the resident may have been omitted from the bath schedule and another acknowledging the worsening of the resident's skin condition over time. The resident's medical record indicated that staff observed and documented the progression of the skin rash and scabbing, with multiple skin assessments noting the presence of scabs, abrasions, and dry skin. Despite these observations, there was a delay in obtaining physician orders for appropriate topical treatment. Requests for anti-itch cream and topical ointment were made, but there was no immediate response from the physician, and the topical ointment was not started until several days after the initial request. The treatment administration record later showed that topical ointments were administered, but only after a delay. Facility policy required timely assessment, reporting, and documentation of changes in condition, as well as documentation of bathing activities or refusals. However, the resident's lack of scheduled bathing and the delay in obtaining and initiating physician-ordered treatment for the skin rash demonstrated a failure to provide care according to orders and the resident's needs. Staff interviews further revealed gaps in communication and adherence to established procedures for both bathing and skin care documentation.
Failure to Assess and Initiate Care for New Pressure Ulcer
Penalty
Summary
A resident with multiple complex medical conditions, including hemiplegia, stroke, stage IV chronic kidney disease, diabetes, and vascular dementia, was identified as being at high risk for pressure ulcer development, as indicated by a Braden scale score of 18. The resident experienced a change in medical condition and was receiving IV fluids and antibiotics for a urinary tract infection. During personal care, a CNA observed a new skin injury on the resident's buttock and reported it to the unit manager and the nurse responsible for the resident's care. Despite this notification, the responsible RN failed to complete and document an assessment of the new skin injury, did not notify the physician, did not obtain or implement treatment orders, and did not report the new injury to the oncoming shift. Subsequent weekly skin assessments by another RN also failed to document measurements or descriptions of the injury, and there was no physician notification or treatment initiation. When the dressing was reported as coming off, another RN assessed and measured the wound but did not initiate standing wound care orders until the physician could be reached during regular business hours. These lapses resulted in a delay in assessment, physician notification, and initiation of appropriate wound care for the resident's newly discovered skin injury. The facility's process for managing new skin injuries was not followed by multiple staff members, as confirmed by interviews and record reviews. The deficiency was identified through review of documentation, staff interviews, and direct observation.
CNA Applied Dressing Outside Scope; RN Failed to Assess and Notify Physician for New Skin Injury
Penalty
Summary
A certified nurse aide (CNA) observed a new, quarter-sized skin injury on a resident's buttock while providing personal care. The CNA reported the injury to the unit manager/wound care nurse and the registered nurse (RN) responsible for the resident's care. Despite being notified, the RN did not complete or document an assessment of the new skin injury, nor did the RN notify the resident's physician or obtain and implement a physician's order for treatment. The CNA independently applied a dressing to the resident's skin injury, a task that was outside the CNA's professional scope of practice according to the facility's job description. The RN did not instruct the CNA to apply the dressing and was unaware that the CNA intended to do so. The CNA's job description specified responsibilities such as reporting to nursing staff and providing care to maintain skin integrity, but did not include independently applying dressings to skin injuries.
Failure to Initiate CPR and Assess for Irreversible Death in Full Code Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to provide basic life support, including CPR, to a resident who was found unresponsive, despite the resident having a full code resuscitation status. The registered nurse (RN) and licensed practical nurse (LPN) involved did not assess the resident for irreversible signs of death, such as rigor mortis or dependent lividity, before deciding not to initiate CPR. The RN also failed to promptly identify the resident's code status and did not communicate critical assessment findings to the administrator, which delayed the initiation of life-sustaining measures. The resident involved had a history of heart disease, anemia, COPD, chronic peptic ulcer, depression, and alcohol abuse, and was moderately cognitively impaired. She was found unresponsive, cold to the touch, and with stiff limbs by staff. Despite these findings, there was no documentation of a thorough assessment for clinical signs of irreversible death, and the RN left the resident's room to check the code status at the nurses' station instead of using available resources nearby. The LPN confirmed the absence of a heartbeat and noted mottled lower extremities but did not document the change in the resident's medical status in the electronic medical record. The RN did not direct the code response as required, failed to call 911 immediately after identifying the resident's full code status, and did not provide a clear report to the administrator regarding the presence or absence of irreversible death signs. As a result, CPR was not initiated until much later, and emergency medical services took over care upon arrival. The lack of timely assessment, documentation, and response to the resident's change in condition led to the cited deficiency.
Failure to Provide Required Supervision for Resident Outside
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of wandering and falls was allowed to go outside unsupervised. The resident, who had diagnoses including cerebral aneurysm, vascular dementia, and major depressive disorder, was observed by a transportation staff member who held the door open for him but did not notify facility staff. The resident sat on a bench outside, where he subsequently fell, sustaining abrasions to his forehead and right knee, and was sent to the Emergency Department. Review of the resident's care plan indicated that he required supervision when outside due to his tendency to wander, with specific interventions stating that staff should stay with him. Multiple staff interviews confirmed that the resident was not safe to be outside alone and should have been supervised at all times, even when seated. The administrator was unaware of the care plan intervention and acknowledged that the resident was in her line of sight but did not provide direct supervision. The lack of adherence to the care plan and failure to provide adequate supervision led to the resident's fall and injury.
Failure to Adequately Address Resident's Wound
Penalty
Summary
The report details a deficiency in the care provided to a resident who suffered a skin tear on her left lower leg. The resident, who had a moderately impaired cognitive status and multiple serious health conditions including paroxysmal atrial fibrillation and peripheral artery disease, received a laceration on her leg after catching it on her wheelchair. Despite the injury, the on-call care provider decided that the wound could be managed within the facility, and the resident's son was informed of the situation. However, the wound continued to bleed over several days, and the facility staff struggled to manage the bleeding effectively. Interviews with various staff members revealed that there was a lack of adequate supplies, such as steri-strips, to properly care for the wound. The nursing staff, including CNAs and RNs, repeatedly changed the resident's dressing as it became saturated with blood, but the bleeding persisted. Despite the ongoing issue, the decision was made not to send the resident to the emergency department, and the family was not re-notified to make a decision regarding further medical intervention. The resident's condition deteriorated, and she passed away shortly after the incident. The facility's policies on neglect and wound care were reviewed, highlighting a failure to provide necessary and adequate care to prevent harm. The staff did not follow the wound care protocol effectively, and there was a lack of communication and decision-making regarding the resident's worsening condition. The assistant director of nursing and the administrator both expressed that they did not believe anything was done incorrectly, despite the continuous bleeding and lack of appropriate supplies.
Failure to Implement Pressure Injury Prevention for High-Risk Resident
Penalty
Summary
The provider failed to assess and implement preventative pressure injury interventions for a resident who was identified as at risk for pressure injuries. The resident was admitted to the facility with a high risk for skin breakdown, as indicated by a Braden scale score. Despite this, the only intervention in place at admission was heel lift boots. The care plan required the resident to be turned and repositioned every two hours, but this was not consistently implemented, leading to the development of a pressure injury on the resident's coccyx. The resident's electronic medical record showed that a request for a bariatric air mattress and wheelchair cushion was made, but these were not ordered until several days later. Weekly skin assessments were signed off as completed but were not actually performed. Interviews with staff revealed a lack of communication and follow-through regarding the resident's repositioning and skin assessments. The resident's care plan included specific instructions for repositioning and skin care, but these were not effectively communicated or executed by the staff. The facility's policy on skin and pressure injury prevention was not adhered to, as evidenced by the failure to prevent the development of pressure injuries in a resident who was at high risk. The staff interviews highlighted gaps in the documentation and communication processes, which contributed to the oversight in the resident's care. The deficiency was identified as non-compliance with the standard of care expected for preventing pressure injuries.
Failure to Monitor Bowel Management Program and Notify Physician
Penalty
Summary
The provider failed to ensure a bowel management program was monitored for a resident who had multiple diarrhea consistency stools and unintentional weight loss. The resident, who was cognitively intact and had ataxic cerebral palsy, experienced significant weight loss over a three-month period. Despite eating between 50 and 100 percent of her meals and taking dietary supplements, the resident's weight dropped from 115.8 pounds to 93.6 pounds. The resident reported having watery bowel movements with every toileting and often had uncontrolled bowel movements, which she attributed to the medications she was given. The medical record revealed that the resident had 48 bowel movements in a 30-day period, with 33 documented as diarrhea loose. However, there was no documentation indicating that the physician had been notified of the frequent loose stools, and the resident continued to receive both a laxative and a stool softener daily despite the diarrhea. Interviews with staff revealed a lack of communication and awareness regarding the resident's condition. Certified nursing assistants (CNAs) were aware of the frequent loose stools and charted the consistency in the electronic medical record system, but registered nurses (RNs) were unable to view this information due to system updates. The MDS coordinator expected nurses to hold the laxative medication when the resident had loose stools, but there was no documentation to support that this was done. The physician assistant was not informed of the resident's condition and had not been notified of the frequent loose stools, which could have contributed to the resident's weight loss. The consulting dietitian was also unaware of the loose stools and depended on staff to notify her of changes in the resident's condition. The facility's policies and job descriptions did not include specific instructions for reporting frequent loose stools to the nurse or physician, nor did they mention holding laxatives or stool softeners during episodes of loose stools. The lack of appropriate and necessary notification to the physician assistant and registered dietitian about the resident's condition, combined with the continued administration of laxatives and stool softeners, contributed to the resident's unintentional weight loss and frequent diarrhea. The facility's failure to monitor and manage the resident's bowel program appropriately led to this deficiency.
Medication Administration and Documentation Failures
Penalty
Summary
The nursing facility failed to ensure proper medication administration and documentation by its staff. One registered nurse (RN) mixed a resident's pills with applesauce and left nutritional supplements and Mirilax on the dining table without ensuring the resident consumed them. The RN documented that the medication was administered, but observation revealed that the resident did not consume all of the Mirilax, leading to inaccurate documentation on the Medication Administration Record (MAR). Another incident involved a licensed practical nurse (LPN) who administered lorazepam and morphine to a resident but failed to document the administration on the MAR. The LPN acknowledged the oversight and confirmed that the medications were given before changing the resident's Foley catheter, as supported by a progress note in the resident's electronic medical record (EMR). Additionally, the facility did not accurately document the administration of tube feeding and water flushes for a resident with a feeding tube. The MAR lacked proper documentation for the nighttime tube feeding and water flushes, and there were discrepancies in the recorded amounts of tube feeding administered. The director of nursing confirmed that staff were expected to observe residents during medication administration and document it immediately, which was not followed in these cases.
Medication Administration Errors
Penalty
Summary
The provider failed to ensure medications were administered as ordered for two residents. For Resident 14, the controlled drug records for clonazepam revealed that the resident was given a 0.25 mg dose in the evening instead of the ordered 0.5 mg dose on multiple occasions. The Medication Administration Records (MARs) inaccurately documented that the 0.5 mg dose was given, while the actual administration was 0.25 mg. This discrepancy was confirmed by a count of the medication blister packs and the documentation logs. The Director of Nursing confirmed that these medication errors occurred and were not reported, investigated, or followed up on as required by the facility's policy. For Resident 32, during a morning medication pass, the registered nurse (RN) administered lisinopril without first reconciling a discrepancy between the pharmacy label and the MAR order. The pharmacy label included instructions to hold the medication if the systolic blood pressure was less than 90, but this instruction was missing from the MAR. The RN administered the medication without taking the resident's blood pressure, as required by the original order. The Director of Nursing confirmed this medication error and noted that no error reports were completed or investigated for this incident either. The facility's policy mandates that staff compare medication labels to MAR orders and reconcile any discrepancies before administration, which was not followed in these cases.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The provider failed to ensure that two residents had prescription medications accurately labeled and that a certified medication aide (CMA) did not alter a prescription medication label. For Resident 14, the Medication Administration Record (MAR) indicated a daily dose of 0.25 mg clonazepam, but the medication blister pack label stated the dose as 'as needed.' The discrepancy was confirmed by the Director of Nursing (DON), Assistant DON, and CMA. Additionally, the CMA had altered the medication label by covering the 'as needed' instruction with a black permanent marker, which is against the facility's policy that only the pharmacy provider can make such alterations. For Resident 32, the registered nurse (RN) administered lisinopril during the morning medication pass. The pharmacy label on the blister pack included an instruction to hold the medication if the systolic blood pressure was less than 90, but this instruction was not present on the resident's MAR. The DON confirmed that staff are expected to compare each blister pack label to the MAR order and reconcile any discrepancies before administering medication. The facility's policies from September 2018 and May 2016 were reviewed, which stated that medication labels should not be altered by nursing personnel and that discrepancies should be checked against the prescriber's orders.
Infection Control Deficiencies in Hand Hygiene and Glove Use
Penalty
Summary
The provider failed to ensure proper infection control practices were followed by an occupational therapist (OT) and an assistant director of nursing (ADON). The OT, while preparing to transport a resident to therapy, did not remove her gloves, perform hand hygiene, or put on a clean pair of gloves after assisting the resident with her wheelchair and adjusting her oxygen tubing. Additionally, the OT used the same gloves to wipe saliva from the resident's mouth and then exited the room without performing hand hygiene. The OT confirmed that she should have performed hand hygiene after glove removal. The ADON, while assisting a resident with toileting, washed her hands but used her wet hands to turn off the faucet handle before drying her hands with a paper towel. She then put on a clean pair of gloves to clean urine spots off the floor, removed her gloves, and washed her hands again, but used her wet hands to adjust the faucet handle. The ADON confirmed that her wet hands should not have touched the faucet handle and that a clean paper towel should have been used to turn off or adjust the faucet handle. The facility's hand hygiene policy was reviewed and it was noted that hand hygiene should be completed after contact with objects in the immediate vicinity of the resident and that the use of gloves does not replace hand hygiene.
Latest citations in South Dakota
Two residents experienced failures in timely implementation of physician orders and provider notification. One resident with cognitive impairment, respiratory failure, pneumonia, and a urinary catheter had a UA/UC ordered after increased confusion, but catheter change and urine collection were delayed and inconsistent, and an antibiotic order faxed for a UTI was left on a reception fax machine and never started before a later order changed therapy based on culture results. Lab reports showing Enterobacter cloacae and susceptibility to a different antibiotic were not consistently documented as reviewed, and the resident continued to exhibit confusion and flank pain until transfer to the ER. Another resident with ESRD on dialysis, hypotension, hypertension, and heart failure had orders for Midodrine with BP parameters and daily Metoprolol, but Midodrine was not given on dialysis mornings and Metoprolol was rarely given on dialysis days, without notifying the physician. Very low BPs were recorded without documented provider notification or repeat checks, despite a TAR requiring monitoring for post-dialysis complications. Interviews and policy review showed expectations to follow orders and notify physicians of abnormal labs, omitted medications, and changes in condition, which were not met in these cases.
Two residents at high risk for pressure ulcers did not receive consistent, individualized prevention and treatment measures, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment and high Braden risk, fully dependent on staff for mobility and hygiene, was repeatedly observed in bed with the head of bed elevated and sliding down, without documented q2h repositioning, individualized pressure-relief interventions, or consistent use of barrier cream, and CNAs and restorative staff were unaware of specific pressure-prevention measures for her. Another resident with multiple comorbidities, prior healed pressure ulcers, and a high Braden score developed recurrent stage II and III pressure ulcers to the coccyx and gluteal fold, a left heel DTI, and a left lateral leg stage II ulcer; ordered wound treatments were not documented as completed on at least one ordered date, he was not on a defined turning schedule despite being largely bedfast, and heel offloading and use of heel boots were inconsistently implemented and documented. In both cases, staff interviews and record review showed that facility practices did not consistently align with the facility’s own skin and pressure injury prevention policy requiring q2h repositioning, appropriate support surfaces, and systematic offloading for bedfast residents.
The deficiency centers on unsafe resident transfers and unsecured chemicals. A resident with hemiplegia and severe cognitive impairment, care planned for a one-person sit-to-stand (STS) lift transfer, was instead manually transferred by a CNA without the lift, during which the resident’s legs gave out, he was lowered to the floor, hit his head, and later was found to have a subdural hematoma. Another resident with severe cognitive impairment and documented inability to meet STS criteria was nonetheless assessed and care planned for STS transfers, while staff and family intermittently pivot transferred her without a gait belt and with inconsistent use of mechanical lifts, amid reports that pocket care plans and Kardex information were not kept up to date. Additionally, surveyors repeatedly observed an open tub room with unlabeled and labeled chemical spray bottles accessible on the tub, and an unattended housekeeping cart in the dining room with toilet bowl cleaner and other disinfectants unlocked and reachable by residents, contrary to staff statements that such rooms and chemicals were to be secured.
The facility failed to consistently honor resident preferences and care‑planned frequency for bathing, resulting in multiple residents going six to ten days or longer between baths despite being scheduled for twice‑weekly showers or baths. Several residents, including those with impaired and intact cognition, reported missed or inconsistent baths, needing to repeatedly remind CNAs, and being told they were skipped due to other residents waiting longer, staffing shortages, or equipment issues. Observations included a resident with long, jagged fingernails and urine odor who reported missed scheduled showers. Review of EMRs and the bath schedule showed numerous missed baths without documented refusals or valid reasons, while the grievance log and resident council minutes documented ongoing complaints from multiple residents about not receiving baths as scheduled. Nursing staff acknowledged receiving complaints and that residents sometimes went more than a week without bathing, despite a facility policy stating residents have the right to choose timing and frequency of bathing and requiring documentation of bathing activity or refusals.
Two cognitively intact residents with significant ROM and mobility limitations did not receive their care-planned restorative nursing programs as ordered. One resident with DM, neuropathy, above-knee amputation, and CKD reported increasing stiffness and weakness and stated that staff no longer brought her for exercises; records showed only sporadic lower extremity and kinetic bike sessions over several months despite physician orders and a care plan for regular AROM and restorative activities. Another resident with RA, polyneuropathy, and prior fractures, who used a power wheelchair, reported not receiving her prescribed exercise program and feeling she was losing strength; her MDS and restorative documentation showed no completed restorative exercises or standing with a walker despite a detailed restorative care plan. Therapy staff and RAs confirmed written restorative recommendations and expectations for 3–6 sessions per week, but reported that two RAs were responsible for about 44 residents, could not see all residents daily, prioritized those more willing or independent, and were unsure when these two residents last received restorative exercises, while the DON acknowledged awareness of staffing difficulties and confirmed the minimal restorative services actually provided.
Staff failed to maintain dignity, hygiene, and privacy for multiple dependent residents. A resident with severe cognitive impairment and depression was left in bed in nightclothes with dried food and juice on her body and linens, and was observed with a dried substance on her nose that was not cleaned over time, despite her reliance on staff for all personal care. Another cognitively impaired resident, dependent on staff for hygiene and dressing, was repeatedly observed wearing a heavily soiled shirt, with food in his beard and thick residue on his fingers, and continued to spill coffee on himself in the dining room without staff assistance or interventions; there was no documentation that he refused care. A third cognitively impaired resident with severe mental illness and risk for abuse and neglect was provided incontinence care while standing at the sink in a shared room without adequate use of the privacy curtain or window blinds, allowing his roommate and potentially others to see him during intimate care, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment, dementia, metabolic encephalopathy, a history of stage II pressure ulcers, and a urinary catheter was left in a dining room for about ten hours without receiving care as outlined in the care plan. The resident’s plan required repositioning every two hours, substantial assistance with toileting hygiene every two to three hours, monitoring of urine output each shift, and extensive assistance with transfers and wheelchair mobility. On the day of the incident, the resident was brought to the dining room in the morning and not returned to his room until evening, and the assigned CNA and LPN did not provide the scheduled care during this time. The facility’s investigation determined that this failure to follow the care plan and provide necessary care for an extended period constituted neglect.
A resident with a history of making allegations of rough care and a care plan requiring all care to be provided by two caregivers was assisted by a single CNA, contrary to the documented "cares in pairs" intervention. The care plan identified manipulative behavior and alleged mistreatment, and specified that two caregivers should be present to address the resident’s needs and observe the entire care session. On one occasion, the CNA entered the room alone and began providing care, after which the resident reported to an LPN that the CNA had been rough, leading to a deficiency citation for failure to follow the resident’s care plan under F684.
Two residents who required two-person assistance with mechanical lifts were subjected to unsafe transfers when CNAs used improperly sized, mispositioned, or incompatible full-body slings and did not follow manufacturer instructions. In one case, a resident newly admitted with a hospital-provided sling was lowered to the floor during a lift transfer after sliding forward in the sling, resulting in reported rib pain but no fractures on X-ray. In another case, a resident’s wheelchair pad and handle became entangled in a large sling during a lift, causing the wheelchair and resident to be lifted off the floor; the sling remained incorrectly positioned at mid-back when the resident was lifted again and moved to bed. Multiple CNAs and nurses reported no recent facility-specific training or competencies on mechanical or sit-to-stand lifts, selected sling sizes by guessing based on body type or using whatever sling was in the room, and lacked clear, updated care plan or Kardex documentation specifying lift type and sling size for residents who required mechanical lifts.
A resident with moderately impaired cognition, Parkinson’s disease, dementia, high fall risk, and moderate pressure-ulcer risk, who required a sit-to-stand lift and maximal assistance for toileting and hygiene, was taken to a beauty shop bathroom by a CMA and left unattended with the lift attached, the door closed, and no call light activated. The resident was later found by a nurse after an extended, unknown period and had transient redness on the buttocks consistent with prolonged sitting. Documentation lacked a post-incident pain and skin assessment. Staff interviews showed there was no clear, consistent process for how often CNAs should check on residents left on toilets, and an observation revealed a staff member failed to change the beauty shop door sign to indicate occupancy, all occurring under a facility neglect policy that defines neglect as failure to provide necessary goods and services to avoid harm.
Failure to Follow Physician Orders and Notify Providers for Infection Management and Dialysis-Related Care
Penalty
Summary
The deficiency involves failures to follow physician orders in a timely manner and to notify providers of significant clinical information for two residents. For one resident with moderate cognitive impairment, respiratory failure, pneumonia, and an indwelling urinary catheter, the physician ordered a UA/UC after the resident’s son reported increased confusion and requested urine testing. The order for catheter change and urine collection was received and noted, but the catheter change documented on the treatment record as due on one date was not completed until early the next morning. Lab reports show urine samples collected on two different dates and times, with one sample having been collected and then recollected. The resident’s son reported being told that a urine sample had sat in the refrigerator too long and had to be recollected, and that the facility did not start the initially ordered antibiotic while the culture was pending. The lab ultimately reported Enterobacter cloacae complex in high colony counts, and the physician ordered cefuroxime, then later discontinued it and ordered nitrofurantoin based on susceptibility results. The cefuroxime order, faxed on a Friday, was not implemented because it remained on a fax machine in the front reception area over the weekend and was not found until the following Tuesday, at the same time the later order to stop cefuroxime and start nitrofurantoin was found. The cefuroxime order was not noted as reviewed by staff, and the preliminary and final culture reports, including susceptibility results showing the organism was not susceptible to cefuroxime but was susceptible to nitrofurantoin, were not consistently documented as reviewed with clear dates and staff identifiers. Progress notes document ongoing confusion, flank pain, and the resident’s belief that there was urine in her oxygen tubing, as well as the son’s concerns and request for transfer to the emergency room. The DON later documented that her investigation found the 7/11 cefuroxime order had not been started because it was discovered only when the 7/15 order to stop it and start nitrofurantoin was located, and interviews revealed uncertainty about why the UA was recollected and that the incident investigation did not address the delayed UA collection or lack of on-call physician notification for preliminary lab results. For a second resident with intact cognition and diagnoses including ESRD on dialysis, hypotension, hypertension, and heart failure, physician orders directed dialysis three times weekly, Midodrine three times daily for hypotension with a parameter to hold if SBP was 120 or greater, and daily Metoprolol Succinate ER for hypertension without hold parameters. The March MAR shows the resident did not receive Midodrine on the mornings of dialysis days and received Metoprolol only once on a dialysis day during a specified period, with no documentation that the physician was notified of these omissions. Dialysis records show pre-dialysis BPs in the low-normal range, and the MAR documents very low BPs on one evening and the following morning, with no documentation that the provider was notified of these low readings. The TAR required monitoring for post-dialysis complications, including hypotension symptoms, twice daily on dialysis days, but only one day in the month reflected documented symptoms. Interviews with nursing staff and the DON confirmed expectations that physician orders be processed within the shift, that abnormal labs and out-of-parameter vitals be reported, and that Midodrine be given before dialysis when within parameters, but also revealed uncertainty about processing timelines, lack of a facility policy on vital sign parameters, and that the physician was not notified about the inconsistent administration of Midodrine and low blood pressures. Facility policies required following all physician orders and notifying the physician when orders were not followed or when there was a significant change in status, but these were not adhered to in these cases.
Failure to Implement Individualized Pressure Ulcer Prevention and Treatment for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and individualize pressure ulcer prevention and care for two residents at high risk for skin breakdown, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment, diabetes, depression, and high Braden risk was dependent on staff for hygiene, repositioning, and transfers. On admission, she had no skin breakdown but was identified as at risk. Her care plan initially addressed potential skin impairment but did not include individualized repositioning or pressure-relief interventions beyond standard admission practices. Staff and leadership later acknowledged that the pressure ulcer prevention measures in place before her ulcer developed were standard for all admissions and not tailored to her specific risk factors. For this resident, documentation showed blanchable redness to the buttocks on a skin assessment, followed by identification of a facility-acquired abrasion to the left buttock and coccyx and additional undescribed areas on the backs of both thighs. The next day, the abrasion on the left buttock was documented as a stage II pressure ulcer, which later increased in size. Observations on multiple days showed the resident lying in bed on her back with the head of the bed elevated and her body bent at the chest, with staff acknowledging that this positioning increased the risk of shearing when she slid down in bed. Interviews revealed that she could not turn herself in bed and required staff assistance for repositioning, yet there was no documentation that she was turned every two hours, and the DON could not find evidence that she refused repositioning or barrier cream. CNAs and a restorative aide reported not knowing what pressure prevention interventions were in place for her, and one CNA left her in bed all day because the resident did not respond when asked if she needed anything, despite the resident’s inability to use the call light or reposition herself. The second resident had multiple serious medical conditions, including spinal stenosis, chronic kidney disease, atherosclerotic heart disease, dysphagia, and protein-calorie malnutrition, and was assessed as high risk for pressure ulcers on the Braden scale. He had a history of multiple pressure ulcers and other wounds that had previously healed, but subsequent skin evaluations documented recurrent redness and pressure areas, including a right gluteal fold pressure ulcer and coccyx involvement. Progress notes identified a bleeding open area under the right buttock, reclassification of a right gluteal fold lesion from MASD to a pressure ulcer, and later documentation of a large coccyx pressure area, a left lateral heel DTI, and a left lateral lower leg stage II pressure blister. His care plan listed multiple active pressure injuries and interventions such as an air mattress, pressure-redistributing cushions, wound treatments, and weekly wound monitoring. Despite these identified wounds and orders, the record showed that ordered wound care treatments were not documented as completed on at least one ordered date, and the DON agreed that if treatments were not signed as completed, they were not done, and that wounds would worsen if treatments were missed. Interviews with nursing leadership and the wound nurse indicated that the resident was not on a formal repositioning schedule, even though standard practice was to reposition residents every two hours, and that his heels were offloaded and repositioned only “as needed.” Staff reported that he often refused to get up in his wheelchair and refused heel lift boots, but refusals and effective approaches were not consistently documented. A PA-C stated she would expect preventative measures such as an air mattress to prevent recurrence of pressure ulcers, and the DON and RN unit manager confirmed that an air mattress was ordered only after multiple pressure injuries were documented. The facility’s own Skin and Pressure Injury Prevention Program policy required offering repositioning at least every two hours for bedfast residents, considering off-loading when the head of bed was elevated, and using special mattresses as indicated, but the documented care and staff interviews showed gaps between these policy requirements and the actual implementation of pressure ulcer prevention and treatment for this resident. Overall, for both residents, surveyors identified failures to consistently implement and document individualized pressure ulcer prevention measures such as scheduled repositioning, appropriate use of pressure-relieving surfaces, barrier creams, and heel offloading, as well as failures to ensure staff understood and followed care plan interventions. These failures occurred despite both residents being clearly identified as high risk for pressure injury and, in the second case, having a documented history of prior pressure ulcers and multiple active wounds.
Unsafe Transfers and Unsecured Chemicals Leading to Resident Injury and Exposure Risk
Penalty
Summary
The deficiency involves failures to ensure safe transfers in accordance with resident care plans and to secure hazardous chemicals from resident access. One resident with hemiplegia following a stroke and severe cognitive impairment, who was care planned to transfer with one staff using a sit-to-stand lift, was transferred by a CNA without the lift from the toilet to a wheelchair. During this transfer, the resident’s legs gave out, he was lowered to the floor, and his head struck the wall, resulting in a skin tear on his left forearm, a bump on the back of his head, and elevated blood pressure and pulse. A CT scan later revealed a subdural hematoma. The DON reported that the CNA had been educated that same morning on the importance of following resident care plans, and the CNA stated she did not use the stand lift because she believed she could complete the transfer faster without it. A second resident with senile degeneration of the brain and severely impaired cognition was also not consistently transferred according to her assessed needs and care plan. Her care plan initially indicated use of a sit-to-stand lift, but a lift assessment documented that she could not bear at least 50% of her weight on one leg, could not sit upright without physical assistance, and could not follow simple instructions, which meant she did not meet the criteria for a sit-to-stand lift. Despite this, the assessment summary still indicated she was to use a sit-to-stand lift for bed-to-chair transfers, and she was care planned to use a sit-to-stand lift until later revised to a full-body mechanical lift. The resident’s family member reported concerns about transfers, including that staff did not use a gait belt, that she had assisted staff with pivot transfers, and that staff sometimes used a sit-to-stand lift and sometimes pivot transferred the resident with two staff. A CNA/CMA described pivot transferring this resident with the assistance of the family member by placing their arms under the resident’s arms and moving her from bed to a bath chair, during which the resident did not follow directions or move her feet, and the CNA/CMA held the resident up while quickly pulling the bath chair under her. Documentation and communication tools used by staff to determine transfer methods were not consistently accurate or up to date. Staff reported relying on the Kardex and pocket care plans to determine how residents should be transferred, and multiple staff acknowledged that pocket care plans were not always kept current. For the second resident, the pocket care plan at one point indicated she was a pivot transfer with one staff, while her family stated she required at least two staff for a pivot transfer and had previously used a mechanical lift in another facility. Later, the undated pocket care plan for her hallway indicated she was to be transferred with a full-body mechanical lift and sling. The DON and administrator confirmed that the initial lift assessment for this resident showed she was not a candidate for a sit-to-stand lift, yet she was care planned to use one. The deficiency also includes unsecured hazardous chemicals accessible to residents in a bathtub room and in the main dining area. On multiple observations, the blue hallway bathtub room door was open with no staff present, and a pink crate on top of the bathtub contained two spray bottles, one labeled Multi-Surface Peroxide cleaner with warnings that it causes skin irritation and serious eye damage, and another unlabeled bottle two-thirds full of an unknown liquid. Staff, including a CNA and RN, stated the bathtub room doors were supposed to be closed and locked to prevent resident access and exposure to unsecured chemicals, and the DON and regional nurse consultant confirmed the presence of the labeled and unlabeled chemicals and that the unlabeled bottle did not contain water. In the main dining room, an unattended housekeeping cart was observed with residents present and no staff nearby. The cart contained an open bottle of toilet bowl cleaner on an unlocked portion of the cart, and additional chemicals, including Multi-Surface Peroxide cleanser and Micro Kill foaming disinfectant cleaner, were stored in a lockable compartment that was left unlocked, with the keys on top of the cart. The administrator verified that the chemicals were not secured from resident access and that the bathtub room was supposed to be closed, locked, and accessible only by staff, and that chemicals were expected to be stored in their original labeled containers in a secure location.
Failure to Honor Resident Bathing Preferences and Scheduled Bathing Frequency
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor residents’ rights to choose and receive bathing at the frequency specified in their care plans and preferences. Multiple residents who preferred bathing at least twice weekly did not consistently receive baths or showers as scheduled, and staff did not consistently document refusals or reasons for missed baths. For one resident with severely impaired cognition, the care plan dated 3/25/26 indicated a preference for two baths per week, yet electronic records from 1/28/26 through 3/25/26 showed she received a bath on 3/9/26 and 3/16/26, refused on 3/13/26, was marked as “not available” on 3/20/26 without any supporting documentation that she was out of the facility, and had no documentation of being offered or receiving a bath on 3/23/26. A family member reported concerns that this resident had only received one shower since admission and raised these concerns to the administrator. Another resident with moderately impaired cognition had a care plan dated 3/25/26 indicating a preference for two baths per week. The bath schedule showed he was to receive baths or showers twice weekly on specific days, and there was no documentation of refusals. However, bathing records from 1/28/26 through 3/25/26 showed gaps of six and seven days between some baths, including a seven‑day interval before a bath on 2/21/26 and a six‑day interval before a bath on 3/13/26. This resident reported that there were times he did not receive a bath for a week, that he had to repeatedly remind staff to get a bath, and that the days he was bathed were inconsistent, sometimes occurring every other day and other times with a week between baths. A cognitively intact resident with a care plan preference for two baths per week was scheduled for baths on two specific days each week, but bathing documentation showed missed baths on multiple dates with no refusals recorded. As a result, there were intervals of seven and ten days between baths. This resident stated he did not receive the showers he was supposed to and was unsure if he would receive a scheduled shower on the day of interview. Another resident with moderately impaired cognition, whose care plan indicated a preference for two to three showers per week and who was scheduled for showers on Sundays and Thursdays, had multiple missed showers without documented refusals and repeated six‑day gaps between bathing. During observation and interview, this resident had long, jagged fingernails, smelled of urine, and reported that showers were sometimes not provided on scheduled days or were changed, and that staff had told him he would not get a shower because the shower was being repaired. The facility’s own bath schedule listed specific days for each of these residents to receive baths or showers, but documentation and resident interviews showed that these schedules were not consistently followed. The grievance log from November 2025 through March 2026 recorded multiple resident complaints and resident council concerns about not receiving baths or showers as expected, including reports from several residents that they had gone extended periods without bathing and that staff told them they were being skipped because other residents had waited longer or due to staffing issues. During a resident council interview, several residents reiterated that baths were not completed as scheduled and described waiting from eight days up to three weeks between baths, as well as equipment issues such as a broken chair that prevented bathing. Nursing staff, including an RN and a restorative aide, acknowledged receiving complaints that residents were not getting baths as scheduled and stated that residents sometimes went more than a week without a bath, and that missed baths could contribute to odors, dignity concerns, and skin conditions. The DON stated she expected residents to be bathed according to their care plan preferences and that refusals should be documented, but she was aware of prior grievances about missed baths. The facility’s bathing policy stated that residents have the right to choose the timing and frequency of bathing and required documentation of bathing activity or refusals and reapproach after refusals, but the documented patterns and interviews showed that these requirements were not consistently met.
Failure to Provide Planned Restorative Nursing Programs for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide ongoing restorative nursing programs as care planned and ordered for two cognitively intact residents with limited ROM and mobility. One resident, with Type 2 DM with diabetic neuropathy, an above-knee amputation, adjustment disorder with depressed mood, and stage 4 CKD requiring dialysis three times weekly, reported frustration that the fingers on her right hand were stiff and that she could no longer make a fist. She stated she felt weaker and believed she was not receiving the exercises she needed, explaining that she previously had exercises but no longer was brought for them. She reported that when she complained to therapy about not getting her exercises, she was told that restorative nursing aides were now responsible for providing them. Record review for this resident showed a physician note directing staff to encourage participation in restorative activities and a physician’s order for staff to encourage restorative activity three times weekly with a progress note to be completed on day shift when done. Her care plan included participation in restorative therapy with a goal to maintain current functional ability and interventions of AROM per therapy and nursing recommendations. Her MDS documented functional limitations in ROM in one upper and one lower extremity and indicated she received only two days of AROM restorative nursing programs in the seven-day look-back period. Restorative documentation from mid-December through late March showed that for lower extremity exercises she was documented as not available on multiple days, refused on several days, and not applicable on others, with only two days of restorative lower extremity exercises provided. For kinetic bike exercises over a three‑month period, she was documented as not available or refusing on multiple days, with several days marked not applicable, and only four days of kinetic bike restorative exercises completed. A second resident, who used a power wheelchair, had limited use of upper and lower extremities, and diagnoses including rheumatoid arthritis, polyneuropathy, and fractures of the right lower leg and foot, reported via an iPad translation device that she had participated in PT on admission and was discharged to a restorative program. She stated she was upset that she had not been receiving her exercise program, had complained to the DOR, and felt she was losing strength and her ability to stand and transfer. Her BIMS score indicated she was cognitively intact. Her MDS showed functional limitation in ROM in one lower extremity and no restorative nursing exercise programs received. Her care plan called for participation in a restorative therapy program to maintain functional abilities, with interventions including AROM, sitting exercises with a 3‑lb green TheraBand, trunk exercises x15 reps, and transfers involving standing with a walker up to 10 minutes. Restorative documentation from late January through late March showed multiple refusals and days marked not applicable, with no documentation that she received lower extremity exercises or stood with her walker for ten minutes during that period. Interviews with therapy staff and restorative aides revealed that therapy had provided written restorative recommendations on transfer forms, and the DON was responsible for setting up the programs. The therapy team expected two restorative aides to complete the recommended exercise programs, including upper and lower extremity exercises three to six times per week for the first resident (arm bike, recumbent kinetic bike, 5‑lb weights, green bands) and a lower extremity program three to six times per week for the second resident (standing with walker for ten minutes, 3‑lb weights, green bands). One restorative aide reported that she and the other aide were responsible for restorative exercises for about 44 residents, each scheduled for 15 minutes daily, and that it was impossible to see all residents when only one aide was working. She stated some residents were prioritized because they were ready, independent in getting to the exercise room, and enjoyed exercising, while others known to refuse were deprioritized when staff were busy. She acknowledged not having completed restorative exercises with the first resident recently and not having done restorative exercises with the second resident in over a month. The other restorative aide confirmed workload challenges, restrictions on being alone with the first resident, difficulty coordinating use of the main therapy room and equipment, and uncertainty about when either resident last received restorative exercises. The DON and regional nurse consultant confirmed that the facility’s policy defined restorative nursing as interventions to promote optimal functioning, that residents with written programs were expected to receive at least 15 minutes per day, and that the first resident had received only seven days of restorative exercises since mid‑December while the second resident appeared to have received none since late January, and they were unaware of the residents’ concerns.
Failure to Maintain Resident Dignity, Hygiene, and Privacy During Personal Care
Penalty
Summary
The deficiency involves failures to maintain resident dignity, hygiene, and privacy for multiple residents who were dependent on staff for personal care. One resident with severely impaired cognition, depression, and senile degeneration of the brain was dependent on staff for dressing, personal hygiene, and transfers with a full body lift. Her care plan required staff to use yes/no questions and clear explanations due to her communication difficulties. Her family reported concerns that she was not being changed regularly, was left in bed in her nightgown until mid-afternoon, and was not assisted out of bed to the dining room for meals. The family also reported finding dried juice on the resident’s stomach and bed sheets on consecutive days, indicating the linens had not been changed, and later finding the resident in bed around mid-afternoon in pajamas with food on her face and clothing. During the survey, the resident was observed in the afternoon with a dried green substance on her nose that remained there over an extended period, despite her dependence on staff for hygiene. Another resident with severely impaired cognition, unclear speech at times, and dependence on staff for personal and oral hygiene and dressing was repeatedly observed with soiled clothing and unclean hands and face. He was first seen lying in bed wearing a white shirt with multiple brown discolorations on the chest and arms. Later the same day, he was observed in the dining room wearing the same soiled shirt and spilling coffee repeatedly onto his clothing protector and shirt without staff offering assistance or interventions to prevent further spillage. That afternoon, he was again observed in bed wearing the same dirty shirt with food in his beard and stated he would have liked staff to change his shirt and that he had trouble with spilling food and drinks and wanted more assistance with eating and drinking. On another day, he was observed twice in the hallway with food in his beard and a thick orange substance on his fingers around his fingernails, as well as food on his shirt, with no indication in the record that he had refused clothing changes or hand and face washing. A third resident with severely impaired cognition, depression, anxiety, and a care plan noting severe mental illness with risk for abuse and neglect did not receive adequate privacy during incontinence care. Two CNAs assisted this resident in his shared room by placing a gait belt, helping him stand at the sink, lowering his pants, removing his incontinence brief, cleaning his private areas, and applying a new brief while his roommate was in bed. The privacy curtain was not pulled far enough to prevent the roommate from seeing the resident, and the window blinds were open, leaving him exposed during personal care. Staff interviews confirmed that residents’ clothing should be changed when soiled, faces and hands washed after meals or when soiled, refusals documented, and privacy ensured by closing doors, blinds, and curtains during personal care. The observations and interviews showed that these expectations and the facility’s dignity and privacy policy were not followed for these residents.
Resident Left in Dining Room for Extended Period Without Required Care
Penalty
Summary
The deficiency involves a resident with severe cognitive impairment who was left in the dining room for approximately ten hours without receiving care as outlined in his care plan. According to the SD DOH Facility Reported Incident, the resident was brought to the dining room at around 8:30 a.m. and was not taken back to his room until 6:31 p.m. that day. During this period, the resident did not receive identified interventions to meet his care needs from the CNA and LPN assigned to him. The facility’s investigation determined that the resident was neglected because his care plan was not followed and necessary care was not provided for an extended period. The resident’s medical record showed he had a BIMS score of 1, indicating severely impaired cognition, and diagnoses of metabolic encephalopathy and dementia. His care plan documented that he was at risk for skin impairment due to a history of stage II pressure ulcers, required repositioning every two hours and as needed, had a urinary catheter with urine output to be documented each shift, and required substantial assistance with toileting hygiene every two to three hours, transferring, and wheelchair mobility. He was also identified as being at risk for falls and was to be treated with respect and dignity and to reside free of mistreatment. Despite these documented needs, the resident remained in the dining room for about ten hours without the planned care being provided. The FRI report noted that the resident had a urinary catheter, could move and readjust himself in his wheelchair, was forgetful, and needed staff assistance with using the bathroom. Although his skin assessment after the incident did not show skin breakdown related to the event and he was not incontinent of bowels, the facility’s investigation concluded that the failure of the assigned CNA to follow the care plan and provide care during the prolonged period in the dining room constituted neglect. Interviews with the DON confirmed that the facility’s investigation found the resident had been neglected by staff on that day because his care needs, as specified in his care plan, were not met for approximately ten hours.
Failure to Follow Care Plan Requiring Two Caregivers During Resident Care
Penalty
Summary
Non-compliance at F684 occurred when a resident who was care planned to receive all care from two caregivers at all times was assisted by a single CNA. The resident had a documented history of making allegations of staff being rough and was identified in the care plan as requiring "cares in pairs" with two caregivers present to address her needs and observe the entire care session. Despite this, the CNA entered the resident’s room alone and began providing care without a second staff member present, contrary to the resident’s care plan and the facility’s expectations. The resident’s care plan, initiated on 10/28/22, identified manipulative behavior and alleged mistreatment as focus areas, noting that the resident might voice allegations of mistreatment or exploitation by caregivers, related to feelings of loss of independence, and might use abusive language. Interventions included assuring the resident she was safe and secure, providing two caregivers to address her needs and observe the entire session, having supervisory personnel observe care delivery as much as possible, and offering staff of certain racial backgrounds when able, based on the resident’s stated preferences and history of accusations. On the date of the incident, the resident reported to an LPN that the CNA had been rough with her during care that was provided without a second caregiver present. Staff interviews confirmed that the resident was known to make accusations, tell inconsistent stories, and sometimes scream even before being touched, and that she was to always receive care with two staff present because of these behaviors and prior allegations. On the day of the incident, staff on duty reported hearing the resident screaming after the CNA entered the room and began helping her, then left to get a second person to assist. The CNA acknowledged going into the room alone and assisting the resident with care, thereby not following the resident’s care plan requirement for two caregivers to be present during care, which led to the cited deficiency under F684.
Improper Mechanical Lift Use and Inadequate Sling Selection for Dependent Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of total body mechanical lifts and appropriate slings for residents requiring two-person assistance for transfers. Contracted travel CNAs and facility CNAs used incompatible or improperly sized and positioned slings, and staff lacked clear, accessible information on which sling size and type to use for specific residents. Surveyors identified that staff often selected sling sizes based on visual estimation of body size or by using whatever sling was present in the room, rather than following resident-specific guidance. Care plans and Kardexes for multiple residents who required mechanical lifts did not specify the type of lift (full body or sit-to-stand) or the correct sling size, leaving staff without written direction. One incident involved a resident who had been admitted earlier that day with a full body lift sling brought from the hospital. During a transfer from wheelchair to bed using a full body lift, two CNAs attached the sling provided by the family and began the transfer. As one CNA attached the lower body sling straps to the lift hooks, the resident moved and slid forward in the sling. The CNAs readjusted the resident and completed attaching the sling, but the resident continued to move and slid toward the edge of the wheelchair seat, causing the sling to tilt downward. Unable to safely complete the transfer, the CNAs lowered the resident to the floor using the upper portion of the sling while the lower portion remained attached to the lift. The resident’s buttocks contacted the floor first, she was then assisted to a lying position, and she reported rib pain; a subsequent chest X-ray showed no breaks or fractures. This event was identified as the start of Immediate Jeopardy at F689. Another observed incident involved a different resident being transferred from a wheelchair to a bed using a full body lift and a burgundy (large) sling. Two contracted travel CNAs placed the sling behind the resident, pulled the lower straps under her thighs, and interlaced the straps. As they began lifting, the resident’s wheelchair pad and the left handle of the wheelchair became caught in the sling, causing the wheelchair to lift off the floor with the resident still seated. While the resident and wheelchair were suspended, one CNA pulled on the wheelchair pad to free it, and the CNAs switched tasks while the resident remained in the air. After lowering the resident and wheelchair back to the floor and freeing the wheelchair handle, they did not reposition the sling, which was noted to be placed too high, with the bottom of the sling at the resident’s mid-back instead of under her buttocks. They then lifted the resident again and transferred her to the bed, with one CNA stating during the lift that the setup was “all wrong.” Interviews with multiple CNAs and nursing staff revealed that many had not received recent or any facility-specific training or competencies on safe use of mechanical lifts and sit-to-stand lifts. Several CNAs reported choosing sling sizes based on the resident’s body type or guessing, and one CNA stated she relied on training from previous employers. Staff were generally unaware of which sling to use for specific residents and could not readily locate up-to-date written resources; binders that were supposed to contain lift and sling information were missing or outdated. A paper list of sling sizes found in a communication binder was acknowledged by an RN as not updated. Another RN stated she did not know residents’ sling sizes and would ask a CNA for guidance. Record review confirmed that not all direct care staff, including CNAs involved in the incidents, had completed required competencies on total body lifts or sit-to-stand lifts after the reported incident, despite having worked shifts since that time. Further review of resident records showed that for several residents who used mechanical lifts, care plans and Kardexes lacked documentation of sling size and, in some cases, did not even specify the type of lift to be used. For example, one resident’s care plan and Kardex indicated a need for two-person assistance with transfers but did not identify any transfer equipment. Surveyors also compared an updated list of transfer equipment to slings stored in residents’ rooms and found discrepancies between listed sling sizes and those actually present or documented in the Kardex for certain residents. The facility’s own sling sizing chart and manufacturer’s instructions for the EZ Way Smart Lift outlined proper sling positioning and sizing parameters, including that the base of the sling should be positioned two inches below the tailbone and the top parallel with the shoulder line, but observed practice and staff statements demonstrated that these guidelines were not consistently followed.
Resident Left Unattended on Toilet Resulting in Potential Neglect
Penalty
Summary
The deficiency involves a resident being left unattended on a toilet in the beauty shop bathroom for an extended period, despite requiring staff assistance and supervision. The resident was later found by the charge nurse sitting on the toilet with the sit-to-stand lift still attached, the bathroom door closed, and the call light not activated. Prior to this, a CNA had noticed the resident’s room call light on, but the resident was not in his room; the CNA turned off the call light and proceeded to answer other call lights without locating the resident. The facility’s investigation identified that a certified medication aide (CMA) had taken the resident to the beauty shop bathroom earlier in the afternoon but did not inform other staff or acknowledge doing so, even though witnesses reported seeing the CMA escort the resident to that bathroom. The resident’s medical record showed moderately impaired cognition with a BIMS score of 8, diagnoses including Parkinson’s disease, unspecified dementia, hallucinations, and sensorineural hearing loss, and a high fall risk with a Morse fall scale score of 75. The care plan documented the need for a sit-to-stand lift for transfers, maximal/substantial assistance for toileting, and dependence on staff for toileting hygiene, as well as a focus on risk for pressure ulcer development related to immobility and incontinence. A Braden scale score of 13 indicated moderate risk for pressure ulcers. After being left on the toilet for an unknown but extended time, the resident was assessed by the charge nurse and found to have slight redness on the buttocks consistent with prolonged sitting on the toilet seat; the redness resolved before the end of the shift. There was no documented pain assessment or skin assessment in the medical record following this incident. Staff interviews revealed inconsistent practices and lack of clear guidance regarding monitoring residents left on toilets. One CNA reported checking assigned residents every two hours and returning to the bathroom within five to ten minutes if a resident did not use the call light, noting that longer periods on the toilet could cause redness from pressure. Another CNA stated that some resident bathrooms were too small for lift equipment, so residents were taken to the beauty shop bathroom, but there was no specific process or policy on when staff should return to assist residents off the toilet; she relied on remembering to go back. During observation, a staff member transferred a resident into the beauty shop and closed the door without changing the door sign from “Vacant” to “Occupied.” The facility’s neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and outlined procedures for investigation and protection of residents, but there was no documentation that audits were conducted to ensure staff understood and implemented resident safety interventions related to this incident.
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