Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Lake Andes Senior Living during CMS and state inspections, most recent first.
Kitchen equipment surfaces and food storage areas were found to be unclean, with buildup of dirt and unidentified substances on the dishwasher and freezer, and improper storage of food items. Staff interviews and cleaning schedules revealed that required cleaning tasks were not consistently completed or documented, contrary to facility policy.
A resident with Alzheimer's dementia and severely impaired cognition, who continued to smoke, did not receive a required quarterly smoking evaluation as outlined in the facility's policy. The care plan specified regular assessments to determine the need for supervision during smoking, but a quarterly evaluation was missed, as confirmed by the ADON.
A resident's oxygen tubing was repeatedly observed on the floor and not replaced, contrary to facility infection control protocols. Staff interviews confirmed that tubing should be stored on the machine and replaced if contaminated, but these practices were not consistently followed.
A resident at risk for elopement exited a facility unsupervised despite wearing a Wanderguard, which alarmed correctly. Staff were occupied with other residents, and the resident was found across the street by a CNA. The resident had a history of exit-seeking behavior, and staffing levels were noted as insufficient. Elopement drills were not regularly conducted, and there was no documentation of such drills.
The facility failed to ensure proper diabetic care for several residents, with inconsistent monitoring and documentation of blood sugar levels and lack of physician notification. Residents experienced both high and low blood sugar levels without appropriate interventions or documentation, highlighting a deficiency in care standards.
The facility failed to manage COVID-19 cases effectively, leading to improper precautions and further transmission among residents. Observations showed that residents were not isolated properly, and staff did not follow proper PPE protocols, such as hand hygiene and mask changes. Additionally, Enhanced Barrier Precautions were not implemented correctly for residents with urinary catheters and wounds, as staff did not consistently use gowns, gloves, or eye protection.
The facility failed to maintain a clean and homelike environment for its 39 residents, with observations of rusted and stained air conditioning units, water-stained ceiling tiles, and dust accumulation on air return grates. Peeling paint and exposed wood on doors and door frames created uncleanable surfaces, while bathroom facilities showed signs of neglect. Cluttered storage areas and uncleanable surfaces in common areas further contributed to the deficiency.
The facility did not have a registered nurse (RN) scheduled for eight consecutive hours on two weekends in May 2023. The executive director was aware of the issue and confirmed that while a nurse was always present, it was not always an RN. Staff schedules and payroll records confirmed the lack of RN coverage on specific dates.
The provider failed to ensure proper labeling and storage of food items for resident consumption. Observations showed that several freezers and a resident refrigerator contained unlabeled and undated food items, some stored for extended periods. The dining services manager confirmed these issues, citing problems with labels smudging or falling off. The provider's policies on food storage and labeling were not followed, leading to this deficiency.
The facility failed to ensure resident safety and well-being due to inadequate infection control and diabetic care. Staff did not follow COVID-19 precautions, and the environment was not maintained as safe and homelike. The diabetic care program did not address hypoglycemic and hyperglycemic risks, and physician notifications were not made according to orders. Additionally, the facility lacked an effective QAPI program.
The facility's QAPI program was ineffective, with deficiencies in infection control and diabetic care. During a COVID-19 outbreak, infected residents shared rooms with uninfected ones, violating policy. The executive director was unaware of issues in diabetic care, including lack of physician notification and missing documentation. The QAPI policy required staff involvement and training, which was not effectively implemented.
The facility did not provide mandatory Quality Assurance and Performance Improvement (QAPI) training to seven staff members, as revealed by a review of their files, which lacked documentation of such education.
The facility failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags. One resident was observed with an uncovered bag under his wheelchair in common areas, while another had an uncovered bag visible from the hallway. The DON confirmed that staff were educated on covering bags, and dignity covers were available, but the Catheter Care Policy did not address this requirement.
The facility failed to provide timely and accurate Medicare notices to three residents before their discharge from Medicare Part A skilled services. One resident did not receive a SNF ABN, and the NOMNC provided had incorrect information. Another resident's NOMNC was unsigned and contained incorrect details, while the third resident received notices without the required two-day notice period. The forms also lacked the provider's address and phone number.
The facility failed to maintain privacy for residents sharing adjoining rooms with a shared bathroom. Bathroom doors were replaced with shower curtains, which did not provide adequate privacy, leading to discomfort and fear among residents. The shared bathrooms were also used for storage or as conference rooms, further compromising privacy. The facility's policy on resident dignity was not followed, and there was no policy regarding the use of shower curtains.
The facility failed to update care plans for two residents, leading to deficiencies in addressing fall, elopement, and infection control risks. One resident's care plan lacked documentation for fall and elopement interventions, while another's did not include enhanced barrier precautions despite having open wounds and a catheter. Staff did not follow necessary protocols, and protective equipment was absent.
The facility failed to update care plans for two residents with specific medical needs. One resident with a central venous catheter for dialysis had an outdated care plan referencing a fistula, while another resident managing her diabetes independently had no care plan reflecting her self-care activities. The facility's care planning policy was outdated and lacked proper identification.
The facility failed to maintain accurate documentation in resident records, with errors in physician notification for abnormal blood sugar levels and incorrect resident information in EMRs. Interviews revealed a lack of written policies on diabetic care and inconsistencies in documentation practices.
A resident with severe cognitive impairment did not have proper documentation of a power of attorney for healthcare, leading to unauthorized release of medical information to a friend. The friend, listed as an emergency contact, gave verbal consent for treatments and was informed about medication changes without formal authorization. Staff interviews revealed a lack of awareness about the need for proper documentation, potentially violating HIPAA regulations.
A resident experienced a significant weight loss without being re-weighed as required by facility policy, and another resident was self-administering insulin without a completed safety assessment or physician's order. The facility's policies for weight monitoring and medication self-administration were not followed, leading to these deficiencies.
A resident's PRN lorazepam order was not renewed beyond 14 days, leading to a lapse in their medication regimen. The facility's staff, including the regional nurse consultant and nursing directors, were unaware of the oversight until it was brought to their attention. The facility's policy requires PRN psychotropic medications to be limited to 14 days unless renewed after a prescriber's examination.
Failure to Maintain Sanitary Kitchen and Food Storage Conditions
Penalty
Summary
Surveyors observed that kitchen equipment surfaces and food storage areas were not maintained in a clean and sanitary condition. The top of the dishwasher had a buildup of an unidentified substance, such as dirt, dust, or dried cleaning chemicals, which remained uncleaned over several days. The freezer contained dirt particles and spilled material on the bottom, and single-serving ice cream cups were stored on the same shelf as frozen bacon. There was also dirt buildup around appliances and preparation tables, with evidence that tables and appliances had not been moved to clean underneath them. These unsanitary conditions were confirmed through multiple observations on different days. Interviews with dietary staff revealed that cleaning responsibilities were shared among all kitchen staff and that a cleaning schedule was in place, requiring daily sign-off. However, the cleaning schedule showed multiple instances where staff had not signed off on their cleaning duties, both during the week of the survey and in the previous four weeks. The dietary services manager acknowledged that some cleaning tasks were not being completed or documented as required. Review of the facility's policy confirmed that food was to be stored in clean, dry, and contaminant-free areas, which was not consistently followed.
Missed Quarterly Smoking Evaluation for Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that smoking evaluations were completed quarterly for a resident who continued to smoke. The resident, who had a primary diagnosis of Alzheimer's dementia and a severely impaired cognition as indicated by a BIMS score of 7, was identified as being at risk for injury related to smoking. The care plan for this resident included interventions such as completing smoking evaluations on admission, quarterly, and as needed to determine the resident's ability to smoke independently or require staff assistance. However, record review showed that a quarterly smoking evaluation was missed, as there was a gap between completed assessments. Interview with the assistant director of nursing (ADON) confirmed that the resident, despite having gone six months without smoking, should have still been considered a smoker and required ongoing evaluations per facility policy. The facility's updated smoking policy required all residents who smoke to be assessed during each quarterly or comprehensive MDS assessment, and further evaluated for safe smoking practices. The ADON acknowledged that a quarterly smoking evaluation had been missed for this resident, which was not in compliance with the facility's policy.
Failure to Follow Infection Control Practices for Oxygen Tubing
Penalty
Summary
A deficiency was identified when a resident's oxygen tubing, specifically the nasal cannula that contacts the resident's face, was repeatedly observed lying on the floor while not in use. On multiple occasions, the tubing remained on the floor even after the resident had left the room, and it was not replaced despite being contaminated. The resident confirmed that staff sometimes rolled up the tubing and placed it on the machine, but at other times allowed it to remain on the floor, and that the tubing was not replaced when this occurred. Interviews with staff, including the ADON and CNAs, revealed that facility protocol requires oxygen tubing to be rolled up and stored on the machine when not in use, and that tubing found on the floor should be replaced. However, observations and resident statements indicated that these infection control practices were not consistently followed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident from eloping, despite the resident being identified as at risk for elopement. On the evening of the incident, the resident, who was wearing a Wanderguard, exited the facility through the front door without supervision. Although the Wanderguard alarm functioned correctly, all staff members were occupied with other residents at the time, and the resident was able to leave the premises. The resident was later found across the street by a CNA and returned to the facility without injury. Interviews with staff revealed that the resident frequently attempted to exit the building and had previously been able to leave the facility without the Wanderguard alarming. The facility's staff, including CNAs and the LPN on duty, confirmed that the resident had a history of exit-seeking behavior and had previously exited the building. The LPN noted that staffing levels during the evening shift were insufficient, which may have contributed to the inability to prevent the elopement. Additionally, the facility's regional nurse consultant and DON acknowledged that elopement drills were not regularly conducted, particularly on the night shift, and there was no documentation available for such drills. The resident's care plan and medical records indicated a known risk for elopement, with multiple documented attempts to exit the facility.
Deficiency in Diabetic Care and Physician Notification
Penalty
Summary
The provider failed to ensure proper care and services for diabetic residents, specifically in monitoring blood sugar levels and notifying physicians when levels were outside the normal range. This deficiency affected four out of seven diabetic residents, leading to instances where blood sugar levels were not managed according to accepted clinical standards. Interviews and record reviews revealed that interventions and timely follow-ups were inconsistently documented, contributing to the deficiency. Resident 38, who has type 1 diabetes mellitus and other health conditions, experienced fluctuating blood sugar levels. On multiple occasions, her blood sugar dropped to dangerously low levels, yet there was no documentation of interventions or physician notifications. Similarly, resident 22, with type 2 diabetes and other serious health issues, had several high blood sugar readings without any record of physician notification. Resident 3, also with type 2 diabetes, had high blood sugar levels recorded without any documented physician contact. Resident 20, who is severely cognitively impaired, had high blood sugar levels without physician notification as well. The facility lacked a written policy on hypoglycemia management or diabetic care, relying instead on standing orders that were not reviewed by the current DON. Interviews with staff, including the ADON, revealed inconsistencies in the process for managing low or high blood sugar levels, with some staff unsure of the facility's policy. The deficiency was further highlighted by the lack of documentation of physician notifications for numerous blood sugar readings outside the normal range.
Removal Plan
- Diabetic residents #3, #20, #22, and #38 who receive insulin will be managed with the glycemic management protocol given by the medical directors' guidelines.
- Nurses (RN and LPN) as well as medication aides have been educated on hypoglycemia and hyperglycemia protocols.
- Nurses are to contact each individual residents' provider in event of a low or high blood sugar reading.
- Nurses were educated to document interventions for low or high blood sugar within the resident's EMR.
- Nurses have been educated on the importance of following each individual resident's guidelines given by the resident's medical provider to properly manage diabetes.
- Nursing staff education was completed by the DON and ADON to ensure those who are currently working are providing appropriate glycemic care and the steps to follow in the event of a low or high blood sugar reading.
- Glycemic management protocol instructs that the nurse on duty will contact the residents' provider during clinical hours or their hospital on-call provider after business hours.
- All nurses and medication aides not on shift will be educated prior to them coming on shift.
- All nurses and medications aides were educated on glycemic management protocols.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Inadequate COVID-19 Management and Infection Control
Penalty
Summary
The facility failed to manage COVID-19 cases effectively among 12 sampled residents, leading to improper precautions and further transmission of the disease. Observations revealed that residents who tested positive for COVID-19 were not isolated properly, with some negative residents remaining in the same room as their positive roommates. Staff were observed not following proper protocols for personal protective equipment (PPE) usage, such as not performing hand hygiene before and after glove use, and not changing N95 masks between rooms. Additionally, there were instances where staff did not wear PPE correctly, such as not securing N95 masks properly or wearing gowns outside of isolation rooms. The facility's records showed a lack of documentation regarding informing residents or their responsible parties about the risks of staying in the same room with COVID-19-positive roommates. Interviews with the Director of Nursing (DON) indicated that while there was an expectation to inform residents and document such communications, this was not consistently done. The facility's COVID-19 outbreak policy required placing residents with confirmed infections in single-person rooms when possible, but this was not adhered to, as evidenced by multiple residents remaining in shared rooms despite positive test results. Further deficiencies were noted in the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and wounds. Observations showed that staff did not consistently use gowns, gloves, or eye protection when providing care to these residents, contrary to the facility's policy. Interviews with staff revealed a lack of awareness and adherence to EBP protocols, with some staff unable to locate necessary PPE or unaware of the requirements for its use. This lack of compliance with infection control measures contributed to the facility's failure to prevent the spread of infections effectively.
Removal Plan
- All COVID-positive residents were moved in with other COVID-positive residents. All negative residents are grouped with well residents with no signs or symptoms of COVID. Other negative residents with known exposure, including resident #6, #38, and resident #8, are in the presumptive area with other presumptive residents.
- Staff have been educated on the importance of keeping all positive residents on isolation for 10 days. Staff are to redirect if they want to come out of their room.
- Staff education was completed by the DON and RN Nurse Specialist to ensure all staff who are currently working and are providing care to positive and presumptive residents knew how to properly DONN and DOFF PPE. PPE is put on prior to entering positive and presumptive rooms. This includes removing the gloves and gown inside the room and performing hand hygiene. The removal of the eye protection and mask happens outside the room. Masks and eye protection are discarded. Hand hygiene is performed again. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on properly wearing an N95 mask. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on proper hand hygiene after DOFFING PPE prior to assisting another resident. All those not on shift will be educated prior to them coming on shift.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for all 39 residents, as evidenced by multiple observations of uncleanable and deteriorating surfaces throughout the facility. Specific issues included rusted and stained air conditioning units, water-stained ceiling tiles, and dust accumulation on air return grates in several rooms. Additionally, there were numerous instances of peeling paint and exposed wood on doors and door frames, creating uncleanable surfaces. The bathroom facilities also showed signs of neglect, with missing caulking, peeling paint, and rusted fixtures. Further observations revealed cluttered storage areas with improperly stored items such as incontinent undergarments and hygiene wipes. The dining room and hallways had stained ceiling tiles and rusted vents, while the bathroom outside the director of nursing's office contained several uncleanable surfaces, including a cracked paper towel dispenser and a rusted menstrual products machine. The facility's executive director and director of nursing did not provide any disagreement or comment during the exit conference with the survey team.
Failure to Ensure RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for eight consecutive hours on two weekends in May 2023. An interview with the executive director revealed that he was responsible for filing the payroll-based journal (PBJ) reports and had been aware of the lack of RN coverage on specific dates. The executive director acknowledged that while there was always a nurse present in the building, it was not always an RN on weekends. A review of the staff schedule and payroll records confirmed the absence of RN coverage on Sunday, May 7, 2023, Saturday, May 27, 2023, and Sunday, May 28, 2023.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The provider failed to ensure that food items for resident consumption were appropriately labeled and stored in a safe and sanitary manner. Observations revealed that three out of five freezers contained food items that were not labeled or dated, including bags of fruit, waffles, French toast, frozen omelets, garlic bread, and frozen vegetables. Additionally, a resident refrigerator in the therapy room contained food items that were not labeled, dated, or discarded by the use-by date, such as fruit, yogurt, coffee creamer, and breaded meat. These items had been stored for extended periods, ranging from 11 to 28 days, without proper labeling or disposal. An interview with the dining services manager confirmed the presence of unlabeled food items in the freezers and resident refrigerator. The manager acknowledged that food items should have been labeled with a date received and an opened date, but noted issues with labels smudging or falling off. The provider's undated Food Storage Policy and the November 16, 2018, Outside Food and Food Storage policy outlined requirements for labeling and discarding food, which were not adhered to. The policies specified that leftover food must be used within seven days or discarded, and foods brought in from outside should be labeled with the resident's name, room number, and date, and discarded after 48 hours.
Deficiencies in Infection Control and Diabetic Care
Penalty
Summary
The facility failed to ensure the safety and well-being of its 39 residents due to inadequate administration by the Executive Director (ED) and Director of Nursing (DON). Key deficiencies included the lack of an effective infection control program, particularly in managing COVID-19 infections. Staff did not follow appropriate precautions, such as enhanced barrier precautions, proper use of personal protective equipment, and hand hygiene. Additionally, the facility did not maintain a safe, clean, and homelike environment, and failed to ensure personal privacy for residents sharing bathrooms. The facility also did not have a registered nurse on duty for at least eight consecutive hours on specified dates. The facility's diabetic care program was insufficient, as it did not address hypoglycemic and hyperglycemic risks for insulin-dependent residents. There were failures in notifying physicians according to blood glucose parameters and documenting interventions in residents' medical records. Interviews with the ED and Chief Operating Officer confirmed these deficiencies. Furthermore, the facility lacked an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the widespread system breakdown in ensuring resident safety and care.
Deficiencies in QAPI and Infection Control Programs
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by several deficiencies. The executive director (ED) acknowledged that while the QAPI committee met monthly with the medical director, there were significant lapses in the infection prevention and control program. During a COVID-19 outbreak, residents with confirmed infections were allowed to share rooms with uninfected residents, contrary to the facility's outbreak policy. The ED admitted this was a mistake and that the policy was not followed. Additionally, the ED was unaware of issues in the diabetic care program, specifically the lack of physician notification according to blood glucose parameters and missing documentation of interventions in the residents' electronic medical records. The facility's QAPI policy outlined a systematic approach to improving quality of life and care, involving all employees in ongoing efforts. However, the ED and Director of Nursing, who were responsible for the program, failed to develop a culture that involved input from staff, residents, families, and care partners. The policy also required leadership and facility-wide training on QAPI, ensuring staff had the necessary time, equipment, and training, which was not effectively implemented. These deficiencies were noted in the context of the facility's broader mission to provide a homelike environment and quality care to residents.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that seven employees, identified as B, C, J, P, Q, X, and Y, received mandatory education on the Quality Assurance and Performance Improvement (QAPI) process. This deficiency was identified through a review of the employees' files, which revealed a lack of documentation indicating that these staff members had been educated on the QAPI process as required by regulation during an extended survey.
Failure to Cover Urinary Catheter Drainage Bags
Penalty
Summary
The provider failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags. Resident 34 was observed on two occasions with an uncovered urinary catheter drainage bag hanging under his wheelchair, once in the dining room and once in the living room. The bag contained visible urine, which compromised the resident's dignity. Similarly, Resident 19 was observed in bed with an uncovered urinary catheter drainage bag hanging from the bed bar, visible from the hallway and half-filled with urine. The Director of Nursing (DON) acknowledged that urinary catheter drainage bags should have been covered and stated that staff had been educated on this matter. Dignity covers were available for all catheters, yet the facility's Catheter Care Policy did not address the need to cover urinary catheter drainage bags. The facility's Promoting/Maintaining Resident Dignity policy emphasized treating residents with respect and dignity, involving all staff in promoting and maintaining resident dignity and rights.
Failure to Provide Timely and Accurate Medicare Notices
Penalty
Summary
The provider failed to ensure that proper Medicare notices were completed and provided in a timely manner for three residents prior to their discharge from Medicare Part A skilled services. Resident 39 did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), and the Notice of Medicare Non-Coverage (NOMNC) provided had incorrect information, including an incorrect end date for coverage. Additionally, the NOMNC form lacked the provider's address and phone number, which are required details. Resident 12 also did not receive a SNF ABN, and the NOMNC provided was unsigned and contained incorrect information, such as an incorrect end date for coverage. The form also lacked the provider's address and phone number. Despite attempts to contact the resident's family, there was no evidence that the NOMNC was properly delivered or acknowledged. Resident 12 was moderately cognitively impaired, which may have impacted the communication process. Resident 38 received both the SNF ABN and NOMNC, but the notices were not provided at least two days before the end of skilled services as required. The forms also lacked the provider's address and phone number. The business office manager responsible for issuing these notices was on leave, and there was no policy in place regarding the required Medicare notices, contributing to the deficiencies observed.
Privacy Breach in Shared Bathrooms
Penalty
Summary
The facility failed to maintain privacy for four residents who shared adjoining rooms with a shared bathroom. Observations revealed that the bathroom doors had been removed and replaced with shower curtains, which did not provide adequate privacy. In one instance, a resident was unable to close the door because there was no door to close, and in another, a resident opened the curtain while seated on the toilet and interacted with surveyors. Conversations between staff and residents could be heard through the curtains, indicating a lack of privacy. Additionally, the shared bathrooms were used for storage or as conference rooms, further compromising resident privacy. Residents expressed discomfort and fear of being walked in on while using the bathroom. The director of nursing confirmed that the curtains did not provide privacy and needed to be changed, while the executive director acknowledged the inadequacy of the curtains and the expense of replacing bathroom doors. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by incidents where a resident entered another's room through the shared bathroom, causing distress. The facility lacked a policy regarding the use of shower curtains or shared bathrooms, and the retractable doors had not been replaced since they broke. The facility's handbook stated residents have the right to privacy, which was not upheld in these instances.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The provider failed to ensure that the care plans for two residents reflected their current needs, leading to deficiencies in care. Resident 139's care plan did not include necessary interventions for fall and elopement risks, despite being identified as a fall and elopement risk. Observations revealed that a fall mat was used, and a Wanderguard was ordered, but these interventions were not documented in the care plan. This lack of documentation indicates a failure to update the care plan to reflect the resident's current risk status and necessary interventions. Similarly, Resident 19's care plan did not include enhanced barrier precautions (EBP) despite having open wounds and an indwelling urinary catheter. Observations showed that staff did not use gowns or gloves when providing care, and there was no signage indicating the need for EBP. Interviews with staff confirmed that they were not following EBP protocols, and the director of nursing acknowledged the absence of necessary protective equipment and signage. This oversight in updating the care plan and ensuring staff compliance with EBP protocols contributed to the deficiency.
Failure to Update Care Plans for Residents with Specific Medical Needs
Penalty
Summary
The provider failed to ensure care plans were revised to reflect the current care needs of two residents. Resident 22, who had a central venous catheter (CVC) for dialysis treatments, had a care plan that incorrectly included monitoring for a bruit and thrill of a fistula, which was not applicable to his current treatment method. The Minimum Data Set (MDS) coordinator acknowledged that the care plan had not been updated to reflect the use of a CVC instead of a fistula. Resident 38, who managed her diabetes by checking her blood glucose levels and self-administering insulin, did not have a care plan that reflected these self-care activities. Despite having a physician order for blood glucose monitoring and insulin administration, there was no physician order for medication self-administration, and the care plan did not document her self-management of diabetes. The facility's Person Centered Care Plan policy, which lacked proper identification and was outdated, did not ensure the care plans were accurately revised to reflect the residents' current needs.
Deficiencies in Resident Record Documentation and Physician Notification
Penalty
Summary
The provider failed to ensure complete and accurate documentation in the resident records for four sampled residents. For Resident 20, the electronic medical record (EMR) indicated that the physician should be notified for blood sugar levels greater than 401, yet there was no documentation confirming that the physician had been notified after a reading above this threshold was recorded. Similarly, Resident 22's EMR showed multiple instances of blood sugar readings above 351 without documentation of physician notification. Resident 34's EMR contained incorrect information referring to another resident, and Resident 38's EMR included documentation errors with references to other residents and lacked evidence of physician notification for abnormal blood sugar levels. Interviews with facility staff, including the Executive Director (ED), Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed a lack of written policies on hypoglycemia management or diabetic care, and inconsistencies in documentation practices. The facility's policy on Resident's Access to Protected Health Information (PHI) was outdated and did not address the accuracy of resident records. The survey team noted these deficiencies during an exit conference with the ED and DON, who did not provide any disagreement or comment on the findings.
Failure to Document Power of Attorney for Healthcare
Penalty
Summary
The provider failed to ensure that a resident had proper documentation of a power of attorney for healthcare, which would have allowed information to be released to the resident's friend. The resident, who had a severe cognitive impairment with a BIMS score of 7, had a friend listed as a contact for care conferences and as an emergency contact. Despite this, there was no documentation indicating that the friend was authorized to make medical treatment decisions or receive medical information on behalf of the resident. The friend had given verbal consent for vaccinations and had been informed about medication changes, but these actions were not supported by a formal power of attorney for healthcare. Interviews with the social services director, regional nurse consultant, and director of nursing revealed a lack of awareness regarding the necessity of having proper documentation in place for releasing medical information. The facility's advanced directives policy outlined the importance of having documents such as a Durable Power of Attorney for Health Care, but this was not adhered to in the case of the resident. The staff acknowledged that the emergency contact was not listed as a power of attorney and that releasing information without proper documentation could potentially violate HIPAA regulations.
Failure to Re-weigh Resident and Incomplete Medication Self-Administration Assessment
Penalty
Summary
The provider failed to ensure that a resident was re-weighed after experiencing a significant weight loss. Resident 11's electronic medical record showed a weight drop from 165 pounds to 156 pounds over 13 days, a 5.45% decrease. Despite the facility's policy requiring re-weighing under nurse supervision for a weight change of three or more pounds, there was no documentation of a re-weigh. Interviews with staff revealed issues with scales and confirmed that the resident had not been re-weighed, nor was there documentation of the resident refusing to be weighed. Additionally, the provider did not accurately assess a resident for self-administration of medication. Resident 38, who had a BIMS score indicating cognitive intactness and a history of diabetes, was self-administering insulin without a completed medication self-administration safety screen or a physician's order authorizing self-administration. Despite progress notes indicating the resident was independently managing her insulin, the necessary physician's order was absent. The facility's policy required a completed safety screen and physician's order before initiating self-administration, which was not adhered to in this case.
Failure to Renew PRN Lorazepam Order
Penalty
Summary
The provider failed to ensure that a resident's as-needed (PRN) lorazepam order was renewed for use beyond 14 days. The electronic medical record (EMR) for the resident showed multiple orders for lorazepam to be administered as needed for anxiety, with varying dosages and frequencies. These orders were active until a specific date, after which they were not renewed, leading to a lapse in the medication regimen. During an interview with the regional nurse consultant, director of nursing, and assistant director of nursing, it was revealed that they were unaware that the PRN lorazepam orders had not been renewed. They acknowledged that the orders were not current and subsequently obtained a new order for the medication. The facility's policy on PRN psychotropic medication emphasizes the importance of managing the resident's medication regimen to promote their highest practicable well-being and requires that PRN anti-psychotic medications be limited to 14 days unless renewed following a direct examination by the prescriber.
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Illustrative
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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Illustrative
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Nursing homes near Lake Andes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Wagner | 13.6 mi | — | 0 | 0 |
| Good Samaritan Society Corsica | 19.9 mi | — | 0 | 0 |
| Platte Care Center | 21.9 mi | ★★★★★ | 4 | 0 |
| Butte Senior Living | 22.7 mi | — | 0 | 0 |
| Avera Bormann Manor | 32.2 mi | ★★★★★ | 9 | 0 |
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