Lake Andes Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Andes, South Dakota.
- Location
- 740 East Lake St, Lake Andes, South Dakota 57356
- CMS Provider Number
- 435097
- Inspections on file
- 15
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 3
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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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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