Bethany Home - Brandon
Inspection history, citations, penalties and survey trends for this long-term care facility in Brandon, South Dakota.
- Location
- 3012 E Aspen Blvd, Brandon, South Dakota 57005
- CMS Provider Number
- 435130
- Inspections on file
- 25
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Bethany Home - Brandon during CMS and state inspections, most recent first.
A CNA/CMA engaged in verbal abuse and neglect by withholding fluids, denying requests for beverages, yelling, and attempting to force-feed several residents in a memory care unit. These actions caused distress and agitation among cognitively impaired residents, and were corroborated by staff observations and interviews.
Multiple residents sustained serious injuries after CNAs failed to use whirlpool bath chair safety belts as required and did not follow care plan instructions for mechanical lift transfers. In two cases, residents fell from bath chairs after the safety belt was removed and staff turned away, resulting in fractures and hospitalization. In another case, a resident was transferred alone with the wrong lift device, leading to a leg fracture. Staff interviews and records confirmed that safety protocols were not followed despite prior training.
A resident with a history of falls and moderate cognitive impairment fell forward from her wheelchair and sustained a head laceration requiring sutures when staff transported her without the required wheelchair foot pedals in place. Staff interviews and record review confirmed that the facility's policy mandated the use of foot pedals for wheelchair users, but the pedals were not attached at the time of the incident, leading to the resident's injury.
Two residents with severe cognitive impairment experienced abuse and neglect by CNAs: one was subjected to aggressive handling and verbal abuse during care, while another was left on a bedpan for an extended period, resulting in a skin injury. Both incidents involved failure to follow care plans and required interventions for dependent residents.
A nurse failed to properly document the administration of controlled medications for a resident, leaving medications unattended and incorrectly recording doses of lorazepam and oxycodone. Discrepancies were found between medication cards, controlled drug records, and the MAR, with some doses not documented or signed out as required. These actions resulted in inaccurate records and a lack of proper accountability for controlled substances.
The facility failed to maintain proper sanitation practices in the kitchen and neighborhood kitchenettes, with expired sanitizer test strips and inconsistent dishwasher temperature logs. Additionally, a CNA was observed handling a resident's food with bare hands, contrary to policy. These deficiencies increased the risk of foodborne illnesses for residents.
The facility failed to ensure proper oversight in the food and nutrition services department, as the dietary director was unaware of nursing home kitchen regulations and no food service audits were conducted. The consultant dietitian's visits were undocumented, and the dietary director's responsibilities, including policy development and kitchen maintenance, were not fulfilled. This lack of oversight increased the risk of foodborne illnesses for residents.
The facility failed to maintain privacy and obtain consent for audio and video monitoring devices in residents' rooms. Observations revealed that 13 residents had monitoring devices without proper signage or consent, compromising privacy. Several residents were unaware of the devices, and their EMRs lacked documentation of consent or care plan updates. Staff were not adequately informed about the devices, and the facility's privacy policy did not address their use.
The facility failed to implement an effective grievance process, compromising residents' rights to file grievances and have them addressed. Issues included lack of documentation, investigation, and follow-up on grievances, as well as outdated policies and no formal tracking system. Residents reported unresolved concerns about food quality and missing personal items, while staff interviews revealed inconsistencies in handling grievances.
The facility failed to accurately code MDS assessments for two residents using seat belts in their wheelchairs. One resident, with intact cognition, used a seat belt daily by choice, while the other, moderately cognitively impaired, rarely used it. Observations and interviews revealed discrepancies in MDS coding, with the director of nursing confirming the seat belts were coded as restraints, despite stating they were not used as such.
A CNA suspected of being intoxicated was allowed to work a weekend shift without thorough investigation by the facility. Despite staff reports of strange behavior and the smell of alcohol, the CNA continued working until termination the following Monday. The facility's failure to enforce its policies on alcohol use and conduct a timely investigation represents a deficiency.
Failure to Protect Residents from Verbal Abuse and Neglect by CNA/CMA
Penalty
Summary
The facility failed to protect multiple residents from verbal abuse and neglect by a certified nurse aide/certified medication aide (CNA/CMA). The incident involved the CNA/CMA withholding fluids from residents during meals as a form of punishment for making a mess or for concerns that they would not eat if given drinks. Additionally, the CNA/CMA denied a resident's repeated requests for coffee, yelled at residents, and attempted to force-feed residents by shoving large bites of food into their mouths while yelling at them to eat. These actions caused distress and agitation among the residents, particularly those with significant memory and cognitive decline residing in a secured memory care unit. The report details that the CNA/CMA also scolded a resident for wanting to change her clothes frequently, attributing it to creating extra work and laundry for staff. Staff interviews and record reviews confirmed that these behaviors were observed and reported by another CNA/CMA, and additional staff corroborated the allegations. The affected residents included those with cognitive impairments who were particularly vulnerable to such treatment, and the incidents occurred in a specialized memory care neighborhood designed to provide a structured and supportive environment. Prior to the incident being reported, there were no documented concerns or disciplinary actions related to the CNA/CMA's care or treatment of residents, aside from previous medication administration errors. The deficiency was substantiated through staff interviews and review of the facility's records, which confirmed that the residents were subjected to verbal abuse and neglect by the CNA/CMA during the provision of care.
Failure to Follow Safety Protocols During Bathing and Transfers Resulting in Resident Injuries
Penalty
Summary
Certified nursing assistants (CNAs) failed to follow established safety protocols during resident bathing and transfers, resulting in serious injuries to multiple residents. In two separate incidents, CNAs removed the whirlpool bath chair safety belt before the residents were ready to be transferred, leaving the residents unsecured. In one case, a CNA turned away from a resident after removing the safety belt to retrieve nail clippers, and the resident fell forward out of the bath chair, sustaining a pelvic fracture. In another case, a CNA removed the safety belt to dry a resident and turned away, leading to the resident falling out of the chair and suffering multiple fractures, including to the spine, pelvis, and tibia. Both residents required hospitalization for their injuries. Additionally, a CNA failed to follow the care plan for a resident requiring transfer with a mechanical total lift and assistance from two staff members. Instead, the CNA transferred the resident alone and used the incorrect lift device, contrary to the resident's care plan and facility policy. This resulted in the resident sustaining an acute fracture of the proximal tibia in her lower left leg. The injury was discovered later when a bruise was noted, and subsequent assessment and imaging confirmed the fracture. The resident was under hospice care at the time of the incident. Interviews and observations confirmed that staff were aware of the facility's policies requiring the use of safety belts during bathing and the need for two staff members during mechanical lift transfers. Documentation showed that the involved CNAs had previously received training on these procedures. Despite this, the protocols were not followed, directly leading to the residents' injuries during routine care activities.
Failure to Ensure Use of Wheelchair Foot Pedals Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, traumatic subdural hemorrhage, and moderate cognitive impairment fell from her wheelchair and sustained a laceration to her forehead that required sutures. The incident took place when the resident was being transported in her wheelchair without the required foot pedals in place, contrary to facility policy. The absence of the foot pedals caused the resident to fall forward out of the wheelchair, resulting in injury. Record review showed that the resident had a care plan identifying her as being at risk for falls, with multiple falls reported in the previous six months, including one that led to her current admission. On the day of the incident, staff responded to a call for help and found the resident on the floor, bleeding from her forehead. The injury could not be controlled with pressure, and the resident was transported to the emergency department, where she received sutures before returning to the facility. Interviews with staff revealed that the use of wheelchair foot pedals was expected and outlined in facility policy, which required pedals to be used unless otherwise care planned. However, at the time of the incident, the pedals were not attached to the resident's wheelchair. Staff acknowledged awareness of the importance of using foot pedals, and the director of nursing confirmed that no formal monitoring mechanism was in place to ensure compliance with this requirement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A cognitively impaired resident residing in a secured memory care unit, who was dependent on staff for activities of daily living and known to be resistive to care, was subjected to verbal and physical abuse by a certified nursing assistant (CNA). The CNA became frustrated while assisting the resident with undressing, aggressively removed the resident's arm from his sweatshirt, and attempted to pry the shirt from his hands, causing the resident to verbally express pain. The incident was witnessed by another staff member, who reported discomfort with the CNA's actions and observed a change in the CNA's demeanor upon realizing she was being watched. The resident had severe cognitive impairment and was unable to be interviewed about the incident. In a separate incident, another cognitively impaired resident who required total staff assistance for toileting and repositioning was left on a bedpan for an extended period of time by a CNA. The resident was unable to reposition herself and was found with linear, slow-to-blanch marks on her buttock, consistent with prolonged pressure from a bedpan. Documentation and staff interviews confirmed that the resident had been placed on the bedpan during the night shift and was not removed until discovered by day shift staff several hours later. The resident's care plan required frequent repositioning and total assistance with toileting, which was not provided as required. Both incidents involved residents with significant cognitive impairment and dependency on staff for care. In the first case, the resident's care plan included specific interventions for resistance to care, such as reassurance and re-approaching after a short interval, which were not followed. In the second case, the failure to remove the resident from the bedpan in a timely manner resulted in a skin injury. The events were substantiated through staff interviews, record reviews, and direct observation, demonstrating failures to protect residents from abuse and neglect.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
A deficiency occurred when a nurse failed to correctly document the administration of controlled medications for a resident. Specifically, the nurse left controlled medications unattended on top of a medication cart and incorrectly signed out three doses of lorazepam on the controlled drug record, while the actual medication card count did not match the documentation. Additionally, the nurse signed out doses of oxycodone on the medication administration record (MAR) but did not document the administration of lorazepam in the MAR, and a scheduled lorazepam dose was documented at a different time. There were also discrepancies in the narcotic count sheets for both lorazepam and oxycodone, with mismatched counts between the medication cards and the controlled drug records. Further review revealed that another nurse administered a dose of oxycodone but failed to sign it out on the controlled drug record. During shift changes and narcotic counts, discrepancies were noted, and requests to correct the narcotic records were not immediately addressed. The nurse responsible for the errors admitted to incorrectly signing out doses and not documenting medication administration in the MAR. These actions and inactions led to inaccurate records and discrepancies in the accountability of controlled substances for the resident.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation practices in the main kitchen and neighborhood kitchenettes, leading to potential risks of foodborne illnesses for residents. Observations revealed that staff were unable to verify the chemical sanitation levels required for cleaning kitchen surfaces, as the sanitizer test strips were expired and not used. Additionally, there was no system in place to document the testing of sanitizer solutions, and the dishwasher temperatures were not consistently recorded, with some rinse cycles failing to meet the manufacturer's required minimum of 180 degrees Fahrenheit. In the neighborhood kitchenettes, the dishwashers were not consistently reaching the required rinse temperature of 180 degrees Fahrenheit, as specified by the manufacturer's manual. Maintenance staff were responsible for overseeing the dishwashers but did not keep logs of temperature checks, and the dishwashers were only monitored about once every three weeks. This lack of consistent monitoring and documentation increased the risk of unsanitary dishware being used for resident meals. Furthermore, a hospice CNA was observed assisting a resident with eating a sandwich using bare hands, contrary to the facility's policy that required the use of gloves or utensils when handling ready-to-serve foods. The CNA later acknowledged the mistake and received additional training. The facility's director of nursing confirmed that the CNA should have worn gloves, highlighting a lapse in adherence to food handling protocols.
Deficiency in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure that the dietitian and dietary director effectively carried out the functions of the food and nutrition services department. This failure was identified through observation, interviews, record reviews, and job description reviews. The dietary director, who had been in her position for two months, was not aware of the regulations applicable to nursing home kitchens and had not seen the necessary policies until the survey week. Additionally, there were no food service-related audits conducted since she started. The consultant registered dietitian visited weekly but did not record these visits, although documentation was made in residents' medical records. The dietary director's position description outlined responsibilities such as consulting with the dietitian, maintaining a clean kitchen environment, and developing policies in compliance with food service regulations. However, these responsibilities were not fulfilled, as evidenced by the lack of oversight in cleaning, sanitization, and record-keeping in the main kitchen and four kitchenettes. The contract for registered dietitian services was not signed by the current facility administrator, and the maintenance director's position description did not include oversight of the kitchenettes or monitoring of dishwasher temperatures. This lack of oversight increased the potential risk of foodborne illnesses for residents receiving meals from these areas.
Failure to Maintain Privacy and Obtain Consent for Monitoring Devices
Penalty
Summary
The deficiency report highlights the failure of the provider to maintain privacy and obtain consent for the use of audio and video monitoring devices in residents' rooms. Observations and interviews revealed that 13 residents had monitoring devices in their rooms, but there was no signage indicating their presence, and consent was not obtained for six of these residents. The devices were used for monitoring purposes, such as fall prevention, but the lack of consent and signage compromised residents' privacy. Several residents were unable to identify the monitoring devices in their rooms, and there was no documentation in their electronic medical records (EMR) indicating that consent had been obtained or that care plans had been updated to reflect the use of these devices. For instance, resident 13's EMR lacked documentation of consent, and the care plan was not updated. Similarly, resident 106 had an audio device in their room without consent or care plan updates, and the device was later removed without explanation. The report also notes that the facility's staff, including newly hired employees, were not adequately informed about the presence and use of these monitoring devices. Interviews with staff members revealed a lack of awareness and training regarding the devices, and the facility's privacy policy did not specifically address the use of monitoring devices. The absence of a formal consent process and the failure to post notices about the monitoring devices contributed to the deficiency in maintaining residents' privacy and confidentiality.
Failure to Implement Effective Grievance Process
Penalty
Summary
The facility failed to implement an effective grievance process, which compromised the residents' right to file grievances and have them addressed appropriately. The provider did not ensure that all written grievance decisions included essential details such as the date the grievance was received, a summary of the grievance, steps taken to investigate, findings, conclusions, and any corrective actions. Additionally, the facility did not maintain grievance documentation for the required period of three years, nor did it make prompt efforts to resolve grievances or keep residents informed of progress. Interviews with residents and staff revealed multiple instances where grievances were not documented or followed up on. Resident 20 expressed ongoing concerns about the quality of food, which were voiced to staff, at resident council meetings, and during care plan conferences, yet remained unaddressed. Similarly, resident 41's husband reported a missing bag of personal items and concerns about the quality of fish served, but these issues were not formally documented or resolved. Staff interviews indicated a lack of clarity and consistency in handling grievances, with some staff not filling out grievance forms for reported concerns. The facility's grievance policy was outdated, and there was no formal grievance tracking system in place. The social services director was unaware of the updated grievance policy and continued to use an outdated form. The life enrichment director documented resident concerns during council meetings but did not fill out grievance forms or receive consistent responses from department directors. The administrator confirmed the absence of a grievance log and formal grievances, indicating a systemic failure to document and address resident grievances effectively.
Inaccurate MDS Coding for Wheelchair Seat Belts
Penalty
Summary
The provider failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents who used seat belts in their wheelchairs. Resident 23, who had intact cognition, used a seat belt on her electric wheelchair by choice and could independently apply and remove it. However, her MDS inaccurately coded the trunk restraint as not used, despite an edit note indicating daily use of the seat belt. Her care plan and restraint assessment confirmed her ability to manage the seat belt independently and her preference for its use for safety. Resident 32, who was moderately cognitively impaired, had a seat belt for wheelchair positioning but rarely used it. Observations showed the seat belt was not fastened, and the resident was unsure of its purpose or her ability to use it. Her MDS inaccurately coded the trunk restraint as not used, with an edit note stating she could remove it herself, although she rarely did. The director of nursing confirmed the seat belts were coded as restraints on the MDS, despite stating they were not used as restraints.
Failure to Investigate Alleged Intoxication of CNA
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a certified nursing assistant (CNA) suspected of being intoxicated while on duty. The incident occurred when staff reported that the CNA was acting strangely and smelled of alcohol during her shift. Despite these concerns, the CNA was allowed to continue working the following weekend without any follow-up investigation by the administration. The police were contacted, but they did not conduct a breathalyzer test as they did not find sufficient evidence of intoxication. The Director of Nursing (DON) was informed of the situation but did not take immediate action to investigate further or remove the CNA from the schedule. The CNA was eventually terminated on the following Monday after a container smelling of alcohol was found in the staff break room. However, the facility's failure to act promptly and investigate thoroughly left residents at risk during the weekend when the CNA continued to work. Interviews with other staff members revealed that they were unaware of any alcohol use in the facility, and the CNA in question had not been seen consuming alcohol. The facility's employee handbook outlines strict policies against working under the influence of alcohol, but these policies were not effectively enforced in this instance. The lack of immediate and thorough investigation into the allegations of intoxication represents a deficiency in the facility's handling of the situation.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
