Dells Nursing And Rehab Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dell Rapids, South Dakota.
- Location
- 1400 Thresher Dr, Dell Rapids, South Dakota 57022
- CMS Provider Number
- 435129
- Inspections on file
- 26
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Dells Nursing And Rehab Center Inc during CMS and state inspections, most recent first.
A resident with diabetes and orthostatic hypotension did not receive blood pressure medications according to physician-ordered parameters. Midodrine and Fludrocortisone were both administered outside of the specified blood pressure ranges, and low blood pressures were not promptly rechecked. CMAs involved were unaware of the facility's blood pressure policy, and required notifications and documentation were not completed as per facility protocols.
The facility did not use current Medicare notification forms or fully complete required information when informing three residents and their representatives about the end of Medicare Part A skilled services. Outdated NOMNC and SNF ABN forms were used, missing key details such as the type of services ending and QIO contact information. Two of the affected residents had severe cognitive impairment, and one had moderate impairment. The social services designee was unaware of the updated requirements and did not document all necessary information during phone notifications.
Surveyors found that staff did not consistently use PPE during high-contact care for residents on enhanced barrier precautions, and urinary catheter care practices were not in line with facility policy, with reused and improperly stored catheter bags and unlabeled supplies. Several CNAs were unfamiliar with updated infection control policies, and documentation of staff education was incomplete. The facility also lacked comprehensive written policies for infection surveillance, communicable disease reporting, and isolation precautions, and expired or unlabeled medical supplies were found in storage areas.
A facility failed to implement and monitor care plans for pressure ulcer prevention, leading to the development of ulcers in three residents. One resident developed a heel ulcer due to delayed use of Prevalon boots, while another had a stage II ulcer without proper cushion support. A third resident had open areas on his buttocks without adequate pressure reduction interventions. The facility lacked documentation and staff training on pressure ulcer care.
The facility inaccurately submitted PBJ data for a federal fiscal quarter, showing no licensed nursing coverage on certain days, despite records indicating otherwise. The administrator, responsible for PBJ submission, was unaware of the discrepancies and speculated manual entry errors might be the cause, though some missing coverage days were not staffed by agency staff.
The facility failed to implement enhanced barrier precautions (EBP) and proper infection control practices. Observations showed a lack of PPE, improper hand hygiene, and expired products in resident care areas. Staff interviews revealed insufficient training and awareness of EBP protocols and infection control measures.
A LTC facility failed to update care plans for several residents, leading to deficiencies in care. Residents experienced falls, pressure ulcers, UTIs, and elopement risks without appropriate updates to their care plans. The facility's care planning process did not consistently reflect residents' changing needs and conditions.
The facility failed to secure chemicals properly, with observations showing unlocked cabinets and rooms containing various chemicals, some outdated or improperly labeled. Staff interviews revealed a lack of awareness and adherence to chemical storage policies, despite clear instructions and expectations for secure storage.
A facility failed to prevent significant medication errors, including a resident receiving another's medications, a non-diabetic resident given insulin, and a resident administered a discontinued medication. These errors highlight lapses in medication verification and staff training.
A resident with severe cognitive impairment experienced significant weight loss due to inadequate monitoring and documentation of meal consumption. Despite requiring assistance with eating, the resident was not consistently encouraged or assisted during meals, and meal intake was poorly documented. The care plan did not address the resident's weight loss, and there was a lack of hydration documentation, contributing to the deficiency.
The facility failed to implement an effective antibiotic stewardship program, leading to repeated antibiotic prescriptions for a resident with chronic UTIs without proper documentation or decision-making tools. Staff inconsistencies in obtaining and documenting orders for urine tests were noted, and the infection preventionist's tracking was limited to a spreadsheet. The facility's infection control policy was not effectively implemented, resulting in multiple residents being prescribed antibiotics without clear lab-confirmed infections.
A controlled medication, morphine sulfate, was not properly secured or accounted for in a facility. RN D did not perform the required narcotic count with LPN R at the end of her shift, leading to the discovery of missing medication the following day. Nurse manager C and the pharmacy investigated the incident, revealing a failure to adhere to the facility's Narcotic Count Policy.
The facility failed to report missing controlled medication, specifically morphine sulfate, to the SD DOH in a timely manner. The nurse manager and administrator were unaware of the reporting timeline and did not follow the facility's policy for reporting potential diversion of controlled substances. The incident was discovered on November 24, but the FRI was not submitted until December 4, highlighting a deficiency in timely reporting and adherence to protocols.
A resident with moderate cognitive impairment eloped from the facility after a door alarm was turned off and not reactivated. The resident was found outside, having left the dining room unnoticed. The incident revealed a lapse in safety protocols related to door alarm management.
A resident's bruise of unknown origin was not reported or investigated according to the facility's policy. The LPN failed to document the bruise, notify the family and physician, or report it to the charge nurse or DON. The DON and administrator acknowledged the lapse in procedure, which was not monitored recently, leading to the deficiency.
The facility failed to maintain the dishwasher, resulting in food scum and limescale buildup. Observations showed the dishwasher had not been cleaned or delimed regularly, with staff unaware of the cleaning schedule. The last recorded deliming was two months prior, contrary to the facility's policy requiring regular maintenance.
A facility failed to report a resident's abnormal blood sugar levels to the doctor as required by the physician's orders. Additionally, a prescription ointment was improperly stored at a resident's bedside without a physician's order or assessment, contrary to the facility's policy. Staff interviews confirmed these deficiencies.
The facility failed to serve adequate portion sizes during a lunch service, with Cook H using incorrect scoop sizes for taco bake, resulting in servings that were less than the menu requirements. Cook H was unaware of the correct portion sizes, and the acting dietary manager was not informed of the issue.
Failure to Administer Blood Pressure Medications per Physician Orders
Penalty
Summary
The provider failed to ensure that blood pressure medications were administered according to physician orders for a resident with diagnoses of type 2 diabetes, orthostatic hypotension, and weakness. Upon admission, the resident had specific orders for Midodrine and Fludrocortisone, both with hold parameters based on systolic blood pressure (SBP) readings. Review of the Medication Administration Record (MAR) revealed that Midodrine was administered six times when the resident's SBP was above the ordered threshold, and was not given five times when the SBP was low and the medication should have been administered. Fludrocortisone was also administered twice when the SBP was above the hold parameter. In addition, low blood pressures were not rechecked until the following day when Midodrine was held, contrary to expectations. Interviews with the Director of Nursing (DON) and Certified Medication Aides (CMAs) confirmed that the staff responsible for administering the medications did not consistently follow the blood pressure hold parameters. The DON acknowledged that the facility's policy required blood pressure to be checked prior to administration and that the physician should be notified if readings were out of parameters. The CMAs involved were not aware they had administered medications outside of the prescribed parameters and were unfamiliar with the facility's Blood Pressure Parameter Policy and notification requirements. Review of job descriptions and facility policies indicated that CMAs and RNs were responsible for observing and reporting symptoms, taking and recording vital signs, and notifying the charge nurse of medication errors. The facility's policies also required that medication errors be reported, the physician and DON notified, and the resident monitored for 24 hours following an error. Despite these policies, the required procedures were not followed, resulting in multiple medication administration errors for the resident.
Failure to Provide Proper and Updated Medicare Coverage Notices
Penalty
Summary
The provider failed to ensure that proper Medicare notices were completed fully and in the required format for three sampled residents prior to their discharge from Medicare Part A skilled services. Specifically, the facility used outdated versions of the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms, despite updated forms being mandated for use as of specific dates. The NOMNC forms did not specify the type of services ending, such as skilled nursing, and lacked required contact information for the Quality Improvement Organization (QIO), including the name and toll-free number. Additionally, the forms did not include all information required when notice was delivered by phone to a resident's representative, such as the last day of covered services, the date liability would begin, and details about the appeal process. The sampled residents included two who remained in the facility after their Medicare Part A coverage ended and one who was discharged home. Among these, two residents had severe cognitive impairment and one had moderate cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. The facility's social services designee (SSD) completed the forms and contacted the residents' representatives by phone, but failed to document all required information on the forms and did not mail annotated copies to the representatives as required. During an interview, the SSD acknowledged being unaware that the forms used were outdated and that new forms were required. The SSD also agreed that the forms were not fully completed according to instructions, including missing information about the type of services ending and the QIO contact details. The SSD was not aware of the specific documentation requirements for telephone notification to representatives, resulting in incomplete records for the residents affected.
Deficient Infection Control Practices and Incomplete Policy Implementation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility’s infection prevention and control practices, particularly regarding the use of enhanced barrier precautions (EBP) and urinary catheter care. Certified nursing assistants (CNAs) were observed failing to consistently wear appropriate personal protective equipment (PPE) when providing care to residents on EBP, such as not donning gowns during high-contact activities like transfers. In one instance, a CNA transferred a resident with open wounds without wearing a gown, despite EBP signage and CDC guidance posted in the facility. Additionally, staff did not always perform hand hygiene after removing PPE or before assisting residents with personal items. The facility’s practices for urinary catheter care and storage were inconsistent with policy and infection control standards. Catheter collection bags were reused, stored in plastic trash bags tied to towel racks, and not always labeled or dated. Staff described and demonstrated cleaning procedures that varied from the written policy, including the use of an incorrect vinegar-to-water ratio for cleaning solutions and leaving cleaning solution in bags for extended periods. Supplies such as normal saline and syringes were found opened, unlabeled, and not properly stored or disposed of in resident rooms and supply areas. Several CNAs were unfamiliar with the revised catheter care policy, and documentation of staff education on new policies was incomplete. The facility’s infection prevention and control program lacked comprehensive written policies and procedures in several required areas. There was no documented system for infection surveillance, reporting communicable diseases, determining the duration and restrictiveness of isolation precautions, or prohibiting staff with communicable diseases from resident contact. The policies provided did not address these elements, and staff interviews confirmed the absence of written guidance, relying instead on verbal instructions or external resources. Expired and unlabeled medical supplies were also found in storage areas, further indicating lapses in infection control practices.
Failure to Implement and Monitor Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and monitor care planned approaches for a resident identified on admission as having potential for pressure ulcer development, leading to the development of a heel pressure ulcer. The resident was admitted for strengthening due to a urinary tract infection and had a black spot on her left heel that was not present upon admission. Despite standing orders for Prevalon boots for pressure ulcer prevention, the resident did not start using them until after the sore developed. The care plan was not revised once the skin alteration was identified, and there was a lack of documentation regarding the skin alteration on admission. Two other residents acquired pressure ulcers after admission due to inadequate implementation and monitoring of care plan approaches. One resident had a stage II pressure ulcer on her left hip, but the care plan was not updated to include the use of pressure-reduction devices like the ROHO cushion. The cushion was not inflated, and there was no cushion in the resident's recliner. The facility's staff were not adequately trained on the use and maintenance of the ROHO cushions, and the care plan lacked documentation of the pressure ulcer's progression to healing. Another resident reported pain in his buttocks, and upon examination, open areas were found. The resident's care plan did not include pressure reduction interventions, and there was no pressure reduction cushion in his recliner. The facility's policy required weekly documentation of wounds, but there was no documentation of the size, number of open areas, or specific locations of the pressure ulcer. The facility failed to ensure that staff were aware of and implemented the necessary interventions for pressure ulcer prevention and care.
Inaccurate PBJ Data Submission for Nursing Coverage
Penalty
Summary
The provider failed to accurately submit Payroll Based Journal (PBJ) data for one federal fiscal quarter, specifically Quarter 4, 2024. The PBJ records submitted to the Centers for Medicare and Medicaid Services (CMS) indicated that there was no licensed nursing coverage for 24 hours on specific dates in September 2024. However, a review of the provider's employee timecards, staffing schedules, and residents' electronic medical records (EMR) showed that there was indeed licensed nursing coverage during those times. An interview with the administrator and nurse manager revealed that the nurse manager was responsible for creating the nursing schedule but did not participate in the PBJ submission process. The administrator, who submitted the records, relied on an electronic payroll system to automatically obtain information from individual staff timecards and manually entered agency staff hours. The administrator was unaware of the discrepancies in the PBJ reports and did not know how to access them. She speculated that the errors might have been due to manual entry of agency staff hours, but some missing coverage days were not staffed by agency staff, leaving the cause of the incorrect reporting unresolved.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to accurately identify and implement enhanced barrier precautions (EBP) for residents with care concerns requiring personal protective equipment (PPE). Observations revealed that there was no PPE available in the hallway or residents' rooms, and residents with wounds or indwelling medical devices were not placed on EBP. For instance, a resident with a wound on her right lower extremity was observed without any PPE or EBP signage in her room, despite having a dressing order for her wound. Interviews with staff indicated a lack of understanding and implementation of EBP protocols, with some staff unaware of the criteria for placing residents on EBP. The facility also failed to utilize appropriate hand hygiene and gloves during resident care. A certified nursing assistant (CNA) was observed performing various tasks, such as removing hair rollers, taking vital signs, and assisting with showers, without proper hand hygiene or glove changes. Shared resident care items, such as razors and lotions, were not disinfected between uses, and expired products were found in multiple areas, including the beauty shop and hopper rooms. Staff interviews revealed a lack of training and awareness regarding the cleaning and disinfection of shared items and the importance of hand hygiene. Additionally, the facility did not appropriately maintain and dispose of resident care items in hopper rooms, the shower room, and the beauty shop. Observations showed expired products, improperly stored items, and a lack of alcohol-based hand sanitizers in these areas. Staff were observed disposing of trash without washing their hands, and there was no clear policy for checking and removing expired products. Interviews with the director of nursing and other staff members highlighted a lack of oversight and responsibility for ensuring proper infection control practices and maintaining a clean and safe environment for residents.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that resident care plans were updated to reflect the current needs of several residents, leading to deficiencies in care. Resident 34 experienced multiple falls, including one that resulted in a laceration requiring emergency room treatment. Despite being identified as at risk for falls, her care plan was not updated with new interventions following these incidents. Similarly, residents 4 and 9, who also experienced multiple falls, did not have their care plans updated with fall prevention interventions, despite the facility's policy requiring such updates. Resident 10, who had a history of urinary tract infections (UTIs), did not have her care plan updated to reflect ongoing issues with UTIs, despite multiple antibiotic treatments. The care plan had not been revised since March of the previous year, failing to address her recurrent infections. Additionally, resident 29, who attempted to leave the facility without staff knowledge, was identified as at risk for elopement, but her care plan did not reflect this risk or the interventions put in place following the incident. Residents 7 and 11 also had deficiencies in their care plans. Resident 7, who developed a facility-acquired pressure ulcer, did not have her care plan updated to include the use of pressure-reduction devices. Resident 11, who was prescribed psychotropic medications, did not have her care plan updated to monitor for adverse effects or include non-pharmacological interventions for her hallucinations and anxiety. These oversights indicate a systemic issue with the facility's care planning process, as care plans were not consistently updated to reflect residents' changing needs and conditions.
Inadequate Chemical Storage and Security
Penalty
Summary
The provider failed to ensure that chemicals were stored securely and in accordance with their written instructions, leading to potential accident hazards. Observations revealed that chemicals were stored under sinks in four different rooms, including the Garden Terrace hopper room, Happy Trails hopper room, beauty shop, and shower room. In each instance, the cabinets or rooms were not locked, and various chemicals, some with broken tops or outdated labels, were accessible. Signs were present indicating that chemicals should be kept in locked cupboards, but these instructions were not followed. Interviews with staff, including CNAs, housekeeping, and the DON, confirmed that there was an expectation for chemicals to be stored in locked areas and not under sinks. However, there was a lack of awareness and adherence to these expectations. The DON and nurse manager were unaware of the unlocked cabinets and the presence of chemicals under sinks, despite previous instructions that products should not be stored there. The facility's chemical safety policy emphasized the safe use and storage of chemicals, but it was primarily focused on dietary staff and food contamination, indicating a possible gap in comprehensive chemical storage practices across the facility.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving incorrect medication administration. Resident 33 was mistakenly given another resident's medications, including Tylenol, Olanzapine, Celecoxib, and Tamsulosin, by a certified medication aide. Similarly, Resident 34 received Carbidopa/Levodopa, a medication not ordered for them, leading to the involvement of poison control to monitor for adverse reactions. Resident 11, who was not diabetic, was mistakenly administered 7 units of NovoLog insulin after being confused with another resident. This error was documented, and the resident's primary doctor and daughter were notified. However, there were no further blood glucose checks recorded in the resident's electronic medical record, and the nurse manager was unsure if any education or review of the error had been completed. Resident 29 received Lorazepam, a medication that had been discontinued, due to a failure to verify the medication in the electronic medication administration record before administration. The medication was not removed from the narcotic drawer, leading to the error. The facility's medication error policy outlines steps to prevent, identify, report, and address such errors, but these were not effectively implemented in these cases.
Failure to Monitor and Document Resident's Nutritional Intake
Penalty
Summary
The provider failed to ensure adequate monitoring and documentation of a resident's nutritional intake, leading to consistent weight loss. During a lunch meal observation, Resident 24, who has severe cognitive impairment and requires assistance with eating, was not adequately encouraged or assisted to consume her meal. The resident consumed only a small portion of her meal, and no documentation of her consumption was made in the electronic medical record (EMR). Interviews with staff revealed a lack of awareness regarding the resident's meal consumption and weight loss, as well as issues with obtaining accurate weights and documenting meal intake. The resident's care plan included multiple focus areas related to nutrition and hydration, yet there was no update addressing her significant weight loss of over 10% in the past three months. The Registered Dietician Licensed Nutritionist noted the weight loss and suggested considering an appetite stimulant and encouraging meal intake. However, meal documentation was incomplete, with many meals lacking records of consumption, particularly evening meals. Additionally, there was no hydration documentation in the EMR, and a task to record supplemental fluids was only added after the observation date. This lack of documentation and monitoring contributed to the deficiency in maintaining the resident's health through adequate nutrition.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adequately implement and monitor an effective antibiotic stewardship program, as evidenced by multiple deficiencies in the management of urinary tract infections (UTIs) and antibiotic use. Resident 10, who had a history of chronic kidney disease, type two diabetes mellitus, and recurrent UTIs, was observed to have been prescribed antibiotics multiple times over several months without clear documentation or consistent use of decision-making tools like the SBAR form. The infection preventionist acknowledged the lack of documentation and the absence of a structured process for determining the necessity of urine dips or urinalysis, which contributed to the repeated antibiotic prescriptions. Interviews with staff, including the infection preventionist and registered nurses, revealed inconsistencies in the process of obtaining and documenting orders for urine dips and urinalysis. Staff were not consistently documenting the reasons for performing urine dips or obtaining urinalysis, and there was no standardized form in use to guide these decisions. The infection preventionist admitted that the facility's tracking of infections and antibiotic use was limited to a spreadsheet discussed at QAPI meetings, and there was no comprehensive system in place to ensure appropriate antibiotic use. The facility's infection control and prevention policy outlined the responsibilities of the infection preventionist, including tracking and reporting antibiotic use and infections. However, the policy was not effectively implemented, as evidenced by the lack of systemic data collection and documentation. The report highlighted that from August to December, multiple residents were prescribed antibiotics more than once, and there was no clear evidence of lab-confirmed infections for all cases. This deficiency in antibiotic stewardship could potentially lead to adverse events associated with antibiotic use, although the report did not explicitly state such consequences.
Failure to Secure and Account for Controlled Medication
Penalty
Summary
The deficiency involved the failure to secure and account for a controlled medication, specifically morphine sulfate, for a resident. On the morning of November 23, 2024, RN D counted the resident's narcotics at the start of her shift and found no discrepancies. However, at the end of her shift, RN D did not perform the required narcotic count with LPN R, who initially refused to conduct the count until RN D insisted. The following day, RN D was called back to the facility to assist in locating the missing morphine sulfate, which was not accounted for. LPN R had already left the facility without resolving the issue. Nurse manager C was informed of the missing six milliliters of morphine sulfate and worked with the pharmacy to investigate the incident. Initially, the missing medication was not considered theft until the pharmacy clarified it as such. The controlled drug receipt/record/disposition form indicated that the last dose of morphine sulfate was administered on November 16, 2024, with six milliliters remaining. The facility's undated Narcotic Count Policy required narcotics to be counted by licensed nursing personnel at the beginning and end of each shift, which was not adhered to in this instance.
Failure to Timely Report Missing Controlled Medication
Penalty
Summary
The provider failed to report the missing controlled medication, specifically six milliliters of morphine sulfate, to the South Dakota Department of Health (SD DOH) in a timely manner. The incident was initially discovered on November 24, 2024, but the Facility Reported Incident (FRI) was not submitted until December 4, 2024. Interviews with the nurse manager and the administrator revealed a lack of awareness regarding the timeline requirements for reporting such incidents to the SD DOH. The nurse manager admitted to not following the facility's policy for reporting potential diversion of controlled substances and only began the paperwork for drug diversion on November 25, 2024, after being informed by the pharmacy that it was a misappropriation of a personal item. The facility's policy on Reporting and Investigating Diversion of Controlled Substances requires that investigations be completed within 48 hours of discovering an incident, with the severity of the theft or loss evaluated for reporting purposes. However, both the nurse manager and the administrator acknowledged that they did not adhere to this policy. The administrator also confirmed the failure to follow the policy for reporting potential diversion of controlled substances. The report highlights the deficiency in timely reporting and adherence to established protocols for handling controlled substances within the facility.
Resident Elopement Due to Inactive Door Alarm
Penalty
Summary
The deficiency involved a resident identified at risk for elopement who managed to leave the facility without staff knowledge. The incident occurred when a certified nursing assistant (CNA) noticed that a fire exit door in the living room was slightly open, and the alarm did not sound. The resident was found standing on the sidewalk by the door, having last been seen eating lunch in the dining room. The resident stated she was going to get hot chocolate, indicating she had left the facility without staff awareness. The failure to ensure the door alarm was reactivated after being turned off led to the resident's elopement. The door alarm system was checked immediately after the incident and was found to be turned off. This oversight in reactivating the alarm system allowed the resident to exit the building unnoticed. The resident was wearing a Tile tracking device and a watch capable of tracking her location, but these measures did not prevent the elopement. The resident involved had a Brief Interview for Mental Status (BIMS) assessment score of 10, indicating moderate cognitive impairment. At the time of the incident, the resident was wearing tracking devices, and her vital signs were within normal limits with no injuries noted. The incident highlighted a lapse in the facility's safety protocols, specifically regarding the management and monitoring of door alarms, which are crucial for preventing elopement in residents at risk.
Failure to Report and Investigate Bruise of Unknown Origin
Penalty
Summary
The provider failed to report and investigate a bruise of unknown origin on a resident's forehead, which was observed on 8/06/24. The bruise was not reported to the nurse manager or the director of nursing (DON) for further investigation. Interviews revealed that the certified nursing assistant (CNA) and licensed practical nurse (LPN) involved did not know how or when the bruise occurred. The LPN had spoken to the resident's daughter, who was unaware of the bruise, and failed to document the conversation or notify the family and physician promptly. The LPN also did not report the bruise to the charge nurse or DON, nor did she document it on the medication administration record (MAR) for daily monitoring. The director of nursing (DON) and the administrator acknowledged that the bruise should have been investigated and reported according to the facility's bruise policy. The policy required that bruises be documented, monitored, and reported to the family and physician. However, the bruise was not documented in the resident's electronic medical record, and the family was not notified. The administrator admitted that the process for reporting bruises was broken and had not been monitored recently, leading to a lapse in following the established procedures.
Dishwasher Maintenance Deficiency
Penalty
Summary
The provider failed to ensure that the dishwasher in the kitchen was adequately cleaned and delimed on a regular basis, leading to a buildup of food scum and limescale. During an initial kitchen observation, surveyors noted that the dishwasher, which was in use for cleaning breakfast dishes, had a line of limescale buildup on the outside of the door, food scum on the outside borders and inside seams of the doors, and limescale on the wash arms and piping inside the machine. Interviews with kitchen staff revealed a lack of knowledge regarding the cleaning schedule, with dietary aide J having never cleaned or delimed the dishwasher and cook I not having been tasked with this responsibility for a long time. The night shift was identified as responsible for these tasks, but there was no evidence of regular completion. Further investigation revealed that the administrator believed the dishwasher was supposed to be delimed weekly, with instructions and a deliming schedule posted on the wall. However, the last recorded deliming was approximately two months prior. The facility's dishwashing policy emphasized the importance of cleaning and sanitizing food preparation equipment to prevent disease, with the dietary manager responsible for monitoring task completion and record accuracy. The failure to adhere to this policy and maintain the dishwasher's cleanliness contributed to the observed deficiency.
Failure to Report Abnormal Blood Sugars and Improper Medication Storage
Penalty
Summary
The provider failed to report abnormal blood sugar levels for a resident as per the physician's orders. The resident had a doctor's order to check blood sugar four times daily and report if levels were below 60 or above 500. On two occasions, the resident's blood sugar levels were recorded as 542 and 517, but there was no documentation that the doctor was notified. Interviews with staff, including an LPN and a nurse manager, confirmed that the high blood sugars were not reported, despite a new policy in place to ensure such parameters are monitored and reported. The administrator was unaware of the failure to report these abnormal results. Additionally, the provider did not adhere to their policy regarding the storage of prescription medications. A resident had a prescription ointment on her bedside table without a physician's order for bedside storage. The resident, who had severe cognitive impairment, was unable to use the ointment independently. Interviews with staff, including an LPN and the DON, revealed that the ointment was intended for staff use during care and should have been stored in the medication room. The facility's policy requires a written order and assessment for bedside medication storage, which was not followed in this case.
Inadequate Portion Sizes Served During Lunch
Penalty
Summary
The provider failed to ensure that adequate portions were served according to the menu during a lunch service, which had the potential to affect all residents receiving the main menu in the facility. The menu for lunch on the specified date included one cup of taco bake and a 2/3 cup portion for the pureed version. However, during the observation of the lunch service, it was noted that Cook H used a 1/2 cup scoop for both the regular and pureed taco bake, resulting in serving sizes that were 50% and 33.33% less than the menu requirements, respectively. Interviews with the kitchen staff revealed that Cook H, who had been working at the facility for about three weeks, was not aware of the correct serving sizes and had been trained to use a 1/2 cup scoop for every recipe. Neither Cook H nor Cook I were aware of the correct portion sizes as listed on the posted menu. The acting dietary manager, Administrator A, was also unaware of the incorrect portion sizes being served, as she had recently taken over the role following the departure of the previous dietary manager.
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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