Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jenkin's Living Center during CMS and state inspections, most recent first.
Unlocked Medication Carts Left Unattended: An RN nurse manager and two LPNs left medication carts unlocked and unattended in multiple areas of the facility, including the nurse’s station, outside a resident’s room, and in the oak center unit. One LPN said she had forgotten to lock the cart, and another LPN in charge of the unit confirmed the cart was unlocked and acknowledged it should always be locked when unattended. The facility policy stated the medication cart should always be locked unless in direct view of the nurse/UAP.
Staff failed to follow infection control practices during resident personal care and catheter care. CNAs and an RN used the same gloves across dirty and clean tasks, touched resident personal items and bedside surfaces after perineal care, and did not clean catheter tubing during one resident’s care. Reusable mechanical lifts were also observed with debris, damaged surfaces, and missing parts, and were returned to the hallway without being disinfected after resident use.
Delayed Call Light Response: A resident reported that call lights were not answered quickly enough when staffing was short, and she became incontinent of bowel while waiting. Her record showed intact cognition, left-sided hemiplegia/hemiparesis, left leg contracture, left foot drop, and need for substantial to maximum assist with transfers. Call light logs documented multiple response times over 20 minutes, including several over 30 minutes, while staff gave differing expectations for response times and the facility policy required prompt answering of call lights and assistance alarms.
Dish Machines Used Before Reaching Required Temperatures: Two dish machines did not reach the required minimum wash and rinse temperatures before dishes were washed. A cook in the main kitchen ran dishes through a machine that reached only 142 degrees for wash and 164 degrees for rinse, and another cook in the second-floor kitchen used a machine that reached 147 degrees for wash and 177 degrees for rinse. Staff stated the machines needed to be run a couple of times to get up to temp, and the admin confirmed the required minimums were 150 degrees for wash and 180 degrees for rinse.
A contracted LPN did not follow the facility's procedure for preparing a syringe driver medication for a resident on hospice, omitting the required addition of distilled water. This medication error was identified during a shift change by another LPN, and it was found that travel staff had not received facility-specific training on syringe driver use.
The facility failed to implement proper infection prevention and control practices, including inadequate maintenance of resident care items, failure to adhere to transmission-based precautions, and lapses in hand hygiene and glove use. Staff were observed not wearing PPE when required, and there was confusion about the type of precautions needed for specific residents. Documentation and communication regarding infection control needs were insufficient, and shared bathrooms were not consistently cleaned after use by residents on contact precautions.
The facility failed to maintain a clean and safe environment in the Pine Village and North Oak care units, with issues such as exposed drywall, sticky floors, and non-functioning hand sanitizers. Staff interviews revealed a lack of a formal policy for maintenance requests, relying on verbal communication or slips.
The facility failed to update care plans for residents receiving hospice services, those on a pureed diet, and residents requiring transmission-based precautions. A resident's hospice care was not reflected in her care plan, and several residents in the feeding assistant program lacked documentation of their assistance. Additionally, care plans did not address transmission-based precautions for residents with wounds or infections, nor did they include necessary interventions for residents on high-risk medications.
A nursing home failed to properly store hazardous products labeled 'Keep Out of Reach of Children' in a memory care unit, affecting at least ten residents. Observations showed that items like mouth rinse and deodorant were accessible to residents with cognitive impairments. Staff interviews revealed no clear policy for storing these products safely, and the Director of Nursing confirmed the lack of a formal process to ensure compliance.
The facility failed to ensure that residents with complicated eating problems, such as dysphagia and pocketing food, were not assisted by paid feeding assistants. Observations showed that non-CNA staff assisted residents on pureed diets, contrary to facility policy. The care plans lacked documentation of residents' participation in the feeding assistant program, and the staff development coordinator was unsure if training covered special diets.
The facility failed to ensure accessible call light systems in two shower/tub rooms and five resident bathrooms. Observations showed missing or inaccessible pull cords, and interviews revealed staff were unaware of these deficiencies. The administrator noted no policy for call light requirements, and documentation of call light audits was not provided.
The facility failed to post daily nurse staffing information in a prominent area accessible to all residents and visitors. The data was located near the visitor screening station and lacked the resident census, clear distinctions between RNs and LPNs, and total nurse staffing hours. The DON admitted to being unaware of all posting requirements and confirmed the absence of a policy for posting nurse staffing data.
A facility failed to ensure an integrated hospice care plan for a resident receiving hospice services. The resident, with recent weight loss and on a pureed diet, began hospice care due to gallstones. Despite hospice availability, there was no specific hospice plan at the nurse's station, and the electronic medical record lacked a physician's order for hospice. The facility's care plan was not updated with hospice specifics, and the pocket care plan did not indicate hospice services, leading to a deficiency in coordinated care.
A resident with severe cognitive impairment experienced an unwitnessed fall, leading to hospitalization for a fractured hip, subarachnoid hemorrhage, and critical Troponin level. The facility lacked fall risk assessments and a Fall Policy prior to the incident. The resident was on Warfarin, but neuro checks were not conducted as per policy. The resident was later admitted to hospice care and passed away.
The provider failed to consistently implement interventions such as regular toileting, checking and changing incontinent briefs, and repositioning for six residents, leading to the development of pressure ulcers. Observations and interviews revealed long wait times for assistance, missed showers, and inadequate documentation and follow-up on care plans.
A resident was left in a mechanical lift sling for over an hour, resulting in significant pain and an abrasion on her leg. Despite the resident's cries for help, staff did not respond, and the incident was not reported or investigated according to facility policies. The DON and ADM failed to ensure the resident's safety and proper documentation of the injury.
The provider failed to ensure consistent and accurate oral care for nine residents. Observations revealed that oral care was not performed before placing dentures in the mouths of residents, and some residents' toothbrushes were dry and unused. Interviews with staff indicated that oral care was inconsistently performed, despite the provider's policies requiring twice-daily oral care.
A resident reported being left in a mechanical lift sling on the toilet for two to three hours, causing pain and discomfort. The incident was not reported to the SDDOH within the required twenty-four hours, and no immediate investigation was initiated by the DON or ADM.
Unlocked Medication Carts Left Unattended
Penalty
Summary
The facility failed to ensure that resident medications were secured when three licensed nurses left medication carts unlocked and unattended. During a fire drill, an RN nurse manager left a medication cart unlocked in the nurse’s station by the elevator and storage room marked room [ROOM NUMBER]. On multiple later observations, a contracted travel LPN left the medication cart unlocked and unattended outside resident 9’s room, in the nurse’s station by the elevator and storage room marked room [ROOM NUMBER], and in the oak center unit. The LPN acknowledged that she had forgotten to lock the cart, stated it was not her normal practice to leave it unlocked, and confirmed that she had left it unattended for a few minutes. An additional observation in the oak center unit showed the medication cart unlocked and unattended while two unidentified CNAs walked past it and four unidentified residents were seated about four feet away in the television area. The LPN in charge of the unit confirmed she had the medication cart keys and acknowledged that the cart should always be locked when unattended. Another RN stated she expected the medication cart to be locked whenever it was not attended by the nurse. Review of the facility’s revised July 2025 Medication Administration policy stated that the medication cart should always be locked unless it is in direct view of the nurse/UAP.
Infection Control Failures During Personal Care and Equipment Cleaning
Penalty
Summary
Infection control practices were not followed during personal care for three residents who were on enhanced barrier precautions, including residents 44 and 6, and during urinary catheter care for resident 2. During observed care for resident 44, a CNA put on gown and gloves without first washing or sanitizing hands, then used the same gloves to gather clothing and supplies, move furniture and equipment, open drawers and bags, provide incontinent care, apply cream, place a clean brief, and assist with a Hoyer lift transfer before removing gloves and washing hands. In a second observation with the same resident, two CNAs again donned gown and gloves without hand hygiene and used the same gloves throughout transfer and incontinent care, including handling wipes, a garbage bag, the resident’s brief, clothing, cream, bed controls, IV pole, and Hoyer lift equipment before removing PPE and washing hands. During personal care for resident 6, a CNA and a contracted travel LPN entered the room on enhanced barrier precautions after using sanitizer and putting on gown and gloves. The CNA placed wet washcloths and a soiled brief on the bedside table with the resident’s personal items, including a call light, drink container, mug, remote control, and straw. With the same gloves, she touched the resident’s clean incontinent supplies, blankets, bedside table, and the tops of the resident’s open drink containers, remote, and call light. The CNA also stated she did not clean the urinary catheter during the care, and the LPN expected gloves to be changed after cleaning the resident and the catheter tubing to be cleaned during personal care. During catheter care for resident 2, an RN put on gloves from her uniform pocket, completed the care, removed the gloves, and then touched used washcloths and used alcohol pads positioned under the catheter tubing before touching the bedside table without washing her hands. Staff interviews and policy review confirmed expectations for glove changes, hand hygiene between tasks, cleaning catheter tubing, and not touching clean items or personal belongings with contaminated gloves. The report also documented that reusable mechanical lifts, including Sara Steady and sit-to-stand devices, were observed with food debris, residue, torn or damaged surfaces, missing clips or grip tape, and were returned to the hallway after resident use without being disinfected.
Delayed Call Light Response
Penalty
Summary
The facility failed to ensure staff responded promptly to a resident who reported being incontinent while waiting for her call light to be answered. During an interview, the resident stated that when the facility was short on staff, her call light was not answered quickly enough and that they "wait forever" to get it answered, which caused her to be incontinent of bowel. She said this was embarrassing and frustrating. The resident was admitted on 2/1/2021 and had an intact BIMS score of 14 on 4/7/26, indicating intact cognition. Her EMR showed diagnoses of hemiplegia and hemiparesis affecting the left side, contracture of the left lower leg, and left foot drop. Her care plan indicated she required substantial to maximum assistance with transfers and that staff were to monitor and document bowel sounds and bowel movement frequency; she was continent of bowel and had a suprapubic catheter in place. Review of her call light response time report from 5/5/26 through 5/20/26 showed eleven response times over 20 minutes and three over 30 minutes. Staff interviews reflected differing expectations for response times, ranging from 3-5 minutes to within 12-15 minutes, while the facility policy stated call lights and assistance alarms were to be answered promptly.
Dish Machines Used Before Reaching Required Temperatures
Penalty
Summary
The provider failed to ensure that two of three dish machines reached the minimum temperatures for the wash and rinse cycles before dishes were washed. In the main kitchen, a cook ran a first tray of dishes through the commercial dish machine and the wash temperature reached 142 degrees and the rinse temperature reached 164 degrees. The cook stated she needed to run the dish machine a couple of times to get it to the minimum temperature and confirmed she did not run it before starting to wash dishes, so the machine did not reach the minimum temperature for the first load. In the second-floor kitchen, another cook ran a tray of dishes through the dish machine and the wash temperature reached 147 degrees and the rinse temperature reached 177 degrees. She stated the wash cycle should reach at least 150 degrees and the rinse cycle at least 180 degrees, and that she did not usually run the dish machine before use. The food service supervisor stated staff had been educated to run the dish machines a couple of times before using them because water sits in the lines and the machines need to get up to temperature, and the administrator confirmed the required minimum temperatures and expected staff to follow the manufacturer's instructions.
Failure to Follow Syringe Driver Medication Preparation Standards
Penalty
Summary
A contracted LPN failed to follow professional standards of practice when preparing a physician-ordered medication for a resident receiving hospice services via a syringe driver. The LPN did not add the required distilled water to the medication mixture, as specified in the facility's syringe driver procedure. This omission was discovered when the oncoming nurse identified an incorrect controlled medication count for morphine during a shift change. The LPN later confirmed in an interview that she had not added the distilled water as instructed. The resident involved was admitted to the facility and was receiving continuous medication through a syringe driver for pain, anxiety, and agitation. The facility's policy required staff to follow a specific procedure for preparing medications for the syringe driver, including the addition of sterile water. While regular staff received training on the use of syringe drivers, travel staff, such as the LPN involved, did not receive this training prior to working shifts and were expected to be educated by their employment agency. The facility's medication administration policy also instructed staff to seek clarification if unfamiliar with a medication or procedure.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, as evidenced by several observations and interviews. In the shower room, used personal care items such as a nail file and a dirty hair pick were found, along with a soiled plastic cup with dried paste, indicating inadequate maintenance and disposal of resident care items. Additionally, staff failed to adhere to transmission-based precautions for residents requiring personal protective equipment (PPE). For instance, a resident with a wound on her toe did not have appropriate signage indicating enhanced barrier precautions (EBP), and staff did not consistently wear gowns when providing care. Multiple staff members were observed not performing hand hygiene or using gloves appropriately. For example, a CNA entered a resident's room without wearing a gown or gloves, despite signs indicating the need for PPE. Another instance involved a staff member not performing hand hygiene before and after administering eye ointment. These lapses in hand hygiene and glove use were observed across various staff members and residents, highlighting a systemic issue in infection control practices. The facility's documentation and communication regarding residents' infection control needs were also inadequate. Several residents' care plans lacked documentation of required precautions, and there was confusion among staff about the type of precautions needed for specific residents. For example, a resident with a history of MRSA did not have clear documentation in her care plan about the need for contact precautions. Additionally, shared bathrooms were not consistently cleaned after use by residents on contact precautions, further compromising infection control efforts.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The provider failed to maintain a clean and safe environment in the Pine Village memory care unit and the North Oak care unit, as observed over several days. In the Pine Village unit, multiple resident rooms had exposed drywall due to gouges in the walls, tangled phone cords, and sticky bathroom floors with strong urine odors. Additionally, a bathroom sink was leaking, and a hand sanitizer dispenser was not functioning. The resident day room also had multiple gouges in the walls. These conditions were observed consistently over three days. In the North Oak care unit, a resident room had chipped and jagged bathroom tiles with exposed cement, and a missing piece of tile was noted outside the doorway. The hand sanitizer dispenser in this room was also not functioning. Outside another resident room, there were gouges and scrapes on the walls with exposed drywall. Interviews with staff revealed a lack of a formal policy for submitting maintenance requests, with staff relying on verbal communication or maintenance slips to report issues. The administrator confirmed the absence of a formal policy for maintenance requests.
Deficiencies in Care Plan Updates and Documentation
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect the current needs of residents receiving hospice services, those on a pureed diet, residents requiring transmission-based precautions, and those needing medication monitoring. For instance, a resident receiving hospice care did not have a care plan that reflected her hospice services, despite being admitted to hospice two weeks prior. The care plan lacked specific goals and interventions related to her hospice care, and there was a delay in obtaining the hospice admitting diagnosis. Additionally, the facility did not update care plans for residents participating in the paid feeding assistant program. Several residents on a pureed diet were assisted by paid feeding assistants, yet their care plans did not document this assistance. The staff development coordinator and speech therapist were responsible for determining which residents could be assisted by feeding assistants, but this information was not consistently reflected in the care plans. Furthermore, the facility failed to document transmission-based precautions in the care plans of residents with wounds or infections. For example, a resident with an open wound on her toe was not placed on enhanced barrier precautions as required. Similarly, residents with cognitive impairments and those on high-risk medications did not have care plans that addressed their specific needs, such as monitoring for medication side effects or interventions for their cognitive conditions.
Failure to Secure Hazardous Products in Memory Care Unit
Penalty
Summary
The deficiency involves the failure of a nursing home to properly store products labeled 'Keep Out of Reach of Children' in a memory care unit, affecting at least ten residents. Observations revealed that products such as mouth rinse, deodorant, toothpaste, and CPAP cleaning wipes were accessible to residents in their rooms, despite signs indicating these items should be stored on a closet shelf. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA), confirmed that there was no clear policy or process in place to ensure these products were stored out of reach for residents with cognitive impairments. The report highlights specific cases, such as a resident with severe cognitive impairment who was not oriented to place or situation, yet had access to potentially hazardous products in her room. The resident's care plan did not include instructions to store personal care products out of reach, despite her impaired decision-making skills and memory issues. Similar issues were identified for other residents, with varying degrees of cognitive impairment, who also had access to products that should have been stored safely. Interviews with the Director of Nursing (DON) and other staff members revealed a lack of a formal process or policy to determine which residents should have restricted access to certain products. The DON acknowledged that products labeled 'Keep Out of Reach of Children' should be stored on closet shelves for cognitively impaired residents to prevent accidents. However, the absence of a structured approach to ensure compliance with this practice resulted in the deficiency observed by the surveyors.
Inappropriate Use of Feeding Assistants for Residents with Complicated Eating Problems
Penalty
Summary
The facility failed to ensure that residents with complicated eating problems were not assisted by paid feeding assistants, as observed in the cases of five residents who were on pureed diets. These residents, identified as having issues such as pocketing food, dysphagia, and other swallowing difficulties, were assisted by individuals who were not certified nursing assistants (CNAs) but rather paid feeding assistants. The facility's policy and training materials explicitly stated that feeding assistants are not permitted to assist residents with complicated eating or drinking problems, including those with dysphagia. Observations and interviews revealed that cosmetologist AA, who was trained as a paid feeding assistant but not a CNA, assisted resident 19 with eating despite the resident's recent weight loss, pureed diet, and hospice care status. Similarly, activities aide Y, also a paid feeding assistant, assisted resident 41 with eating. The staff development coordinator, who was new to the role, was unsure if the training covered residents with special diets, and the speech therapist did not consider issues like pocketing food or the need for altered food textures as complicated feeding issues. The facility's records and interviews indicated a lack of documentation in the care plans of residents 6, 7, 15, 19, and 41 regarding their participation in the feeding assistant program. The interdisciplinary team, based on the speech therapist's recommendations, determined resident participation in the program, but the care plans did not reflect this. The facility's policy required that feeding assistants only assist residents without complicated eating problems, yet the feeding assistant list did not exclude any residents, and care plans did not specify which residents required CNA assistance.
Inaccessible Call Light Systems in Resident Areas
Penalty
Summary
The facility failed to ensure that call light systems were accessible to residents in several areas, including two shower/tub rooms and five resident bathrooms. Observations revealed that the wall-mounted call lights in the bathrooms of certain resident rooms did not have pull cords and were not accessible if a resident was on the floor. Additionally, the cords for the call lights in other bathrooms were wrapped around the call light box, making them inaccessible. Furthermore, there was no call light available in one of the shower rooms, and the tub room's call light also lacked a pull cord. Interviews with staff members, including an activity aide and an LPN, indicated a lack of awareness regarding the absence of call lights in certain areas. The activity aide mentioned that the shower room was rarely used, but the toilet in that room was used by residents. The LPN stated that he did not leave residents alone in the shower room but stood outside the door until they were done. The administrator acknowledged the absence of a policy regarding the minimum requirements for call lights and believed that a call light was not necessary in the shower room because staff would be present with the resident. However, documentation of call light audits for functionality was not provided by the end of the survey.
Inadequate Posting of Nurse Staffing Information
Penalty
Summary
The provider failed to ensure that the daily nurse staffing information was posted in a prominent area accessible to all residents and visitors. The staffing data was observed to be located in an inconspicuous location near the visitor screening station, rather than in a more visible area such as in front of the receptionist. Additionally, the posted staffing data did not include the resident census, nor did it provide a clear distinction between registered nurses and licensed practical nurses. The total number of nurse staffing hours for each shift was also missing. During an interview, the director of nursing acknowledged that the staffing data was not posted prominently and admitted to being unaware of all the requirements for the posted nurse staffing data, including the need for the resident census and total hours worked per nursing discipline. Furthermore, there was no policy in place regarding the posting of nurse staffing data.
Lack of Integrated Hospice Care Plan for Resident
Penalty
Summary
The facility failed to ensure an integrated plan of care was developed and accessible between the nursing staff and hospice agency for a resident receiving hospice services. The resident, who had a recent weight loss and was on a pureed diet, began receiving hospice services due to gallstones, with no surgery recommended. Despite the hospice agency being available 24/7, there was no specific binder or paper records at the nurse's station regarding the resident's hospice plan, and the electronic medical record lacked documentation of a physician's order for hospice. Interviews with facility staff revealed that while hospice consent forms were kept in the resident's paper medical record, the joint care plan had not been completed. The Director of Nursing (DON) contacted hospice to obtain the care plan and physician's order, which were not initially available. The facility care plan was expected to be updated with the hospice plan specifics, but the updated care plan lacked a resident-centered goal and specific interventions, directing instead to previous focus areas and interventions. The hospice care plan, dated when the resident was admitted to hospice, indicated ongoing updates would be communicated to the LTC facility, which was responsible for integrating changes into their care planning system. However, the facility's pocket care plan did not indicate the resident received hospice services. The facility's agreement with the hospice provider required a joint plan of care, but this was not effectively implemented, leading to a deficiency in coordinated care for the resident.
Unwitnessed Fall Leads to Hospitalization and Death
Penalty
Summary
A resident with severe cognitive impairment, indicated by a Brief Interview for Mental Status (BIMS) score of 7, experienced an unwitnessed fall in their room at 10:25 p.m. The resident was found lying on their back and complained of right knee pain. Despite being on Warfarin, a blood thinner, neuro checks were not conducted as per the facility's Emergency Procedures policy, which only required them if the resident hit their head. After being assisted off the floor, the resident complained of right hip pain and was given acetaminophen. The physician and family were notified of the fall. The following morning, the resident exhibited fixed pupils and unusual behavior, prompting a nurse to assess them. The resident's blood pressure was found to be low, leading to their transfer to the emergency room. The resident was diagnosed with a fractured right hip, a subarachnoid hemorrhage, and a critical Troponin level, indicating a heart attack. The resident was admitted to the hospital and later returned to the facility under hospice care, where they passed away. Interviews with the facility's administrator and director of nursing revealed that no fall risk assessments or Fall Policy and Procedures were in place before the incident.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The provider failed to ensure consistent implementation of interventions such as regular toileting, checking and changing incontinent briefs, and repositioning for six residents who developed pressure ulcers after their admission to the facility. Resident 15 was observed lying in the same position for several hours and reported waiting up to five hours for staff assistance. She also mentioned that staff refused to help her use the toilet, leading to incontinence. Her daughter corroborated these issues, noting long wait times for call light responses and missed showers. Resident 15's care plan required frequent repositioning and toileting assistance, which were not consistently followed, contributing to her stage III pressure ulcer and other care deficiencies. Resident 14 was not offered toileting after breakfast and had not been checked or changed since early morning. Staff admitted there was no place to document toileting frequency, and the resident's care plan indicated a moderate risk for pressure ulcers, requiring frequent repositioning. Resident 13 was found with a saturated incontinent brief and two open areas on her coccyx, which were pressure ulcers. Staff were unaware of the last time she was checked or changed, and there was no barrier cream applied during the observation. Her care plan included monitoring skin with all cares and repositioning, which were not adequately followed. Resident 5, who wore incontinent briefs but was not incontinent, reported having a sore on her buttocks for about a month. She was not assisted to the bathroom when needed, and her care plan indicated she was at risk for skin breakdown. Resident 12 developed an unstageable pressure ulcer on her right lateral foot, and Resident 2 had a pressure ulcer on her mid-back spine. Both residents had care plans requiring frequent repositioning and other interventions, which were not consistently implemented. The facility's policies on perineal care, pressure sore prevention, and resident-centered care standards were not adequately followed, leading to these deficiencies.
Failure to Protect Resident from Injury Due to Mechanical Lift Sling
Penalty
Summary
The provider failed to ensure that a resident was free from injury caused by the use of a mechanical lift sling. The resident reported being left in the sling in her bathroom for at least two to three hours, during which time she cried, prayed, and tried to call for help but was not heard. The resident experienced significant pain from the sling pressing into her leg, which resulted in a darkish purple pink line running from the middle of her right upper thigh around to the back of her thigh. The resident's electronic medical record indicated she had mild cognitive impairment and required the use of a mechanical total lift with assistance from two staff members for transfers. The incident was reported to the Director of Nursing (DON) and the Administrator (ADM), but no investigation was initiated, and the wound care nurse was not notified to assess the injury. The DON confirmed the resident's allegation and instructed a registered nurse to perform a skin check, which revealed an abrasion consistent with the edge of the lift sling. The resident stated that she had hollered for help for three hours and could hear staff members laughing and talking. The ADM reviewed the facility's recording cameras and confirmed that the resident had been left in the mechanical lift sling for one hour and 41 minutes. Despite this, the ADM did not consider the incident a reportable event to the South Dakota Department of Health and did not initiate an investigation. The facility's policies on mechanical lift use and abuse/neglect/exploitation of residents were reviewed. The mechanical lift policy required staff to confirm that the resident was in a comfortable and safe position before leaving and that the call light was within reach. The abuse/neglect policy mandated that any injury or event be communicated to a member of the Quality Assurance and Performance Improvement (QAPI) team and followed by an investigation if abuse or neglect was suspected. However, these policies were not followed, as the incident was not reported, investigated, or properly documented, and the wound care nurse was not involved in assessing the resident's injury.
Inconsistent Oral Care for Residents
Penalty
Summary
The provider failed to ensure consistent and accurate oral care for nine residents. Observations revealed that oral care was not performed before placing dentures in the mouths of residents 16 and 17. Resident 18's dentures were left in overnight, and oral care was not completed during morning care. CNA N was unable to determine how long the dentures had been left in the resident's mouth without any oral care. Additionally, resident 19's toothbrush could not be located, and CNA O was unaware of the resident's oral care status. Resident 20's oral care was inconsistently performed, with LPN P expressing concerns about using a toothbrush due to the resident's teeth grinding habits. Further observations on the Pine Village unit showed that every toothbrush examined was dry and appeared unused, and mouth rinse bottles were dated and appeared full. Resident 2's dentures were in her mouth, and her toothbrush was dry, indicating a lack of oral care. Resident 4 reported that her oral care was not always done daily, and her partial denture remained in her cup. Resident 5's toothbrush was dry with hard bristles, and resident 3's battery-operated toothbrush was also dry and appeared unused. Interviews with staff, including the DON and ADON, revealed that the expectation was for oral care to be completed every morning, but it was still at the resident's discretion. The provider's policies stated that oral care should be performed twice daily and as necessary, with specific instructions for the care of residents with dentures. However, the observations and interviews indicated that these policies were not consistently followed, leading to deficiencies in the oral care provided to the residents. The lack of proper oral care documentation and the failure to adhere to the established policies contributed to the identified deficiencies.
Failure to Report Allegation of Neglect
Penalty
Summary
The provider failed to report an allegation of neglect made by a resident to the South Dakota Department of Health (SDDOH) within twenty-four hours. The resident reported being left in a mechanical lift sling on the toilet in her bathroom for at least two to three hours, causing her significant discomfort and pain. Despite the resident's cries for help, no staff members responded. The incident was reported to the Director of Nursing (DON) and the Administrator (ADM), but no immediate investigation was initiated, and the event was not reported to the SDDOH as required by policy. The DON instructed a registered nurse to perform a skin check and document the incident in the resident's electronic medical record (EMR), but no further action was taken. The ADM confirmed the incident occurred and reviewed facility camera recordings and staff interviews, which verified the resident had been left in the sling for an extended period. The facility's policy mandates that any suspected abuse or neglect be reported and investigated promptly, but this protocol was not followed in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Watertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Watertown | 0.7 mi | ★★★★★ | 29 | 2 |
| Estelline Nursing And Care Center | 20.5 mi | ★★★★★ | 0 | 0 |
| Avantara Lake Norden | 22.3 mi | ★★★★★ | 2 | 1 |
| Avantara Clark City | 30.5 mi | ★★★★★ | 7 | 0 |
| Avantara Milbank | 31.8 mi | ★★★★★ | 12 | 0 |
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