Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Medicine Wheel Village during CMS and state inspections, most recent first.
A CNA failed to respond appropriately to call lights and did not provide required ADL, toileting, and incontinence care to two dependent residents during a night shift. One resident, with multiple comorbidities and moderate cognitive impairment, was left without toileting assistance after using the call light, and only received help when an LPN and RN intervened. Another resident, with obesity, TBI, contracture, and documented need for two-person assist and scheduled toileting, was not checked or toileted as care-planned. Both residents were later found with heavily saturated incontinence products and urine-soaked beds, and one developed moisture-associated skin damage to the buttocks.
Staff failed to follow professional standards when a physician verbally instructed the DON to have nurses borrow a controlled medication (Lorazepam 0.5 mg) from one resident and administer it to another resident experiencing anxiety after other comfort measures failed. Because the ordered medication was not available on site, the pharmacy was closed, and the family declined ER transfer, an LPN removed a Lorazepam tablet from the first resident’s medication card and gave it to the second resident. This action bypassed facility policies requiring proper ordering, accountability, and use of controlled drugs only for the resident for whom they were prescribed, and the administrator, DON, and consultant pharmacist later acknowledged that borrowing medications between residents is not acceptable practice.
Staff failed to follow food safety and hand hygiene practices during meal prep and service. Surveyors observed a broken dishwasher, use of a 3-compartment sink with expired sanitizer test strips, inconsistent sanitizer log documentation, and staff handling food, dishes, carts, and resident drinks with contaminated gloves or without washing hands. A dietary manager and a dietary aide were observed touching food, utensils, and serving items in ways that did not match facility policy.
A facility failed to post the daily nursing staffing information in a location readily visible to residents, staff, and visitors, and the posted Staffing Census Sheet did not clearly identify what the numbers represented. The sheet was placed high on a wall behind a staff-only area, was only posted in one hallway, and a resident in a wheelchair said it was too high to read until lowered. Staff said the numbers reflected scheduled hours, leadership hours were not included, and review showed entries listing no RN on duty on multiple days, including one entry the administrator said was inaccurate because RN leadership was in the building and available to assist residents.
Therapeutic diets not served as ordered: staff served whole or oversized meat portions, including one-inch pieces and whole cutlets, to residents ordered mechanical soft, ground meat, renal, consistent carb, and NAS diets. A dietary aide relied on memorized diet information instead of resident diet cards, added dessert to all trays including carb-controlled diets, and no ground meat was prepared. Record review showed several residents had physician orders for altered textures and/or swallowing or chewing issues, while the RD and dietary manager stated mechanical soft diets required smaller, moist meat pieces.
Care plans were not revised to reflect the current needs of three residents. A resident with dementia, anxiety, and depression expressed tearfulness and suicidal statements, but her care plan did not include those symptoms, triggers, or nonpharmacological interventions. A resident with schizophrenia had refusal-of-care behaviors and mental health follow-up, but his care plan did not identify his symptoms or interventions. A resident with chronic foot pain had constant pain documented in the MDS and multiple pain orders, but her care plan did not include a pain goal or interventions.
The facility failed to document attempted alternatives before using bed rails for multiple residents and failed to complete required quarterly side rail assessments for several others. Observations found quarter-length side rails in use on several beds, and interviews showed some residents used the rails to get in and out of bed or sit up, while others did not recall consent or education. Record review showed the assessments often lacked documentation of risks, signatures, and prior alternatives, and the DON confirmed alternatives were not attempted before rail installation.
Medication Room Temperature Not Monitored: The facility failed to ensure the medication room was maintained within a proper temperature range for safe medication storage. Staff observed the room felt significantly warmer than the hallway, but only refrigerator and freezer temperatures were documented; there was no monitoring or documentation of the medication room temperature itself. RN/staff development K, RN/IC C, LPN/restorative nurse N, and the DON all stated they were not aware of any temperature monitoring for the room, and the DON was not aware the room needed to be kept between 59 and 86 degrees F.
Infection control practices were not followed during resident care involving EBP, transfers, insulin administration, and wound care. CNAs provided direct care to a resident with a pressure ulcer and urinary catheter without wearing gowns as required, a nursing assistant used the same gloves while changing a brief, transferring a resident with a chronic leg wound and MRSA history, and then moved a total body lift without cleaning it. An LPN applicant and an RN/skin and wound nurse also failed to perform hand hygiene at required points during insulin administration and dressing changes.
A CNA/activity staff member failed to report residents' allegations of neglect, documented during a resident council meeting, to the administrator as required by policy. This resulted in a delay of several days before the administrator and the SD DOH were notified, violating the required 24-hour reporting timeframe for such allegations.
The facility failed to respond to resident council concerns about loud TVs at night and nursing care being performed in public areas. Residents reported that complaints heard by staff had no follow-through, and one resident said the noise made her physically sick. Meeting minutes and grievance logs showed repeated concerns about loud TVs/radios, staff taking vital signs, giving insulin, combing hair, and adjusting clothing in shared areas, but the issues were not consistently documented or resolved. Observations confirmed a resident’s TV was loud enough to be heard in nearby rooms, and the DON and administrator acknowledged that care in the dining room and the loud TV volume had not been addressed.
A resident with schizophrenia did not have an accurate PASRR Level I evaluation after the diagnosis changed from unspecified mood disorder to schizophrenia. The chart showed a prior PASRR finding of unsubstantiated mental illness, a physician note changing the diagnosis to schizophrenia, and a Risperdal order, but SS staff did not submit a new Level II referral because they were unaware of the diagnosis change. Facility policy required PASRR screening to be completed accurately before each admission using all available records.
Failure to document effectiveness and adverse reactions of a newly ordered antidepressant. A resident with dementia, anxiety, and depression was started on fluoxetine after becoming more tearful, but the record contained only one nursing note after the medication began. Staff observed the resident sleeping much of the time, and she told staff she was tired of doing the same things, missed her children, did not want to live anymore, and should try to kill herself. The DON and administrator confirmed there was no consistent documentation of symptoms, no documented basis to judge whether Prozac was helping, and no monitoring of adverse reactions on the TAR as done for other psychotropic meds.
The dietary manager was not certified as required. She had been employed as the dietary manager for years, had not completed a DM course previously, and was only recently enrolled in a certification course after being encouraged by the RD. The administrator confirmed she remained uncertified, and the employee file contained no documentation of prior DM course completion.
Medical Director did not attend and meaningfully participate in QA meetings at least quarterly. QA meetings were held every four to five weeks in person and via Zoom, but the Medical Director was only given information after the meetings rather than attending quarterly. The facility’s QA policy listed how problems were to be addressed but did not identify the QA committee members or required attendance frequency.
Failure to implement an effective antibiotic stewardship program was identified. The facility’s policy required antibiotic use protocols, infection criteria, antibiotic timeouts within 48-72 hours, trend review, antibiogram use, audits, and written reports, but staff only maintained monthly and annual antibiotic lists. RN/IC staff stated they used McGeer criteria in practice without written documentation, relied on common knowledge for suspected UTI evaluation, and did not complete antibiotic effectiveness reviews after initiation. The DON reported there were no written forms, no infection trend documentation, no antibiogram use, no action plan, no data collection forms, and no education records related to antibiotic stewardship.
The facility failed to provide a well-balanced diet that considered residents' preferences and dietary needs. Residents were not given meal choices, and if they refused the meal, they were only offered soup. Food portions were inconsistent due to short staffing, and the registered dietician was not informed of menu substitutions. The facility's policy to provide meals according to residents' needs and preferences was not consistently followed.
The facility failed to submit Payroll Based Journal (PBJ) data for Quarter 1, 2024, to CMS on time. The administrator and outsourced CFO were aware of the submission requirements, but a staff member from the CFO's office missed the deadline by one day. The facility's policy mandates timely submission of staffing information, which was not followed for this quarter.
The facility failed to timely report incidents involving two residents to the SD DOH. One resident experienced a knee injury during a transfer, which was not immediately documented or reported, leading to a delayed diagnosis of a tibial fracture. Another resident had an unwitnessed fall, and despite her complaints of pain, the incident was not promptly documented or reported. The DON admitted to falling behind in reporting duties, resulting in incomplete and delayed notifications to the SD DOH.
The facility failed to provide therapeutic diets as prescribed by physicians for 16 residents. Meals served did not align with approved menus, and there was no documentation or approval from the dietician for substitutions. All residents received the same meal without differentiation between their prescribed diets. The dietary manager admitted to making substitutions without notifying the dietician, and the administrator acknowledged challenges in adhering to prescribed diets due to resident preferences.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with open wounds. Staff did not wear gowns or gloves during transfers or wound care, despite the presence of EBP signage and supplies. Interviews revealed a lack of understanding of the EBP policy, with staff believing it was only necessary for residents with multi-drug resistant organisms (MDROs). The facility's policy required EBP for all residents with wounds, highlighting a discrepancy in practice.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfers, as required by regulations. The resident was transferred twice, with the POA informed but no documentation of bed hold information provided. Social services staff were unaware of the need to report each transfer, and the Ombudsman confirmed not receiving notifications.
A resident's PRN lorazepam order was not renewed beyond the 14-day limit, despite being administered 21 times over a period. The facility's policy requires PRN orders for psychotropic medications to be renewed every 14 days, but the order was not updated until after the medication had been used extensively. Interviews with the DON and an LPN revealed they were unaware of the lapse in renewal, leading to a deficiency in medication management.
A resident received food that was not prepared to the correct temperature due to a malfunctioning warming cabinet thermometer. The dietary staff did not recheck or reheat pureed meals to ensure they were above 135°F before serving. The facility's policy on food temperatures was not followed, and the maintenance department was aware of the issue for months without resolution.
Neglect of ADL and Toileting Care by CNA Resulting in Incontinence-Related Harm
Penalty
Summary
The deficiency involves a CNA’s failure to provide required ADL care and toileting assistance to two dependent residents during a night shift, resulting in neglect. On the night in question, an LPN observed that the traveling CNA repeatedly refused to answer residents’ call lights, spent time on her cell phone, and did not toilet residents or change their incontinence products. When one resident activated her call light, the CNA entered the room, turned off the call light, and left without assisting the resident. Shortly afterward, the call light was activated again, and the LPN responded, finding that the resident needed to use the bathroom and reported that the CNA would not help her. The LPN, with an RN, then assisted the resident to the toilet, provided hygiene care, and returned her to bed. The first resident involved had multiple medical conditions, including arthritis, a history of hip fracture, a chronic non‑pressure ulcer of the right lower leg, a bone density disorder, and mild dementia, with a BIMS score indicating moderately impaired cognition. Her care plan required total assistance with ADLs, dependence on staff for all transfers using a Hoyer lift, staff assistance with toileting or bedpan use, hygiene assistance as needed, and turning and repositioning every one to two hours while in bed. Despite these documented needs, the CNA did not provide the required toileting and hygiene assistance when the resident requested help via the call light, and the resident’s needs were only met when the LPN and RN intervened. The second resident involved also had significant medical and functional limitations, including obesity, arthritis, muscle weakness, encephalopathy, a history of traumatic brain injury, a left lower leg contracture, and mild dementia. His care plan indicated a self‑care deficit related to his traumatic brain injury and contracture, and required extensive assistance from two staff with a sit‑to‑stand lift, as well as two‑person assistance with toileting and hygiene. Staff were to assist him with toileting upon waking, before and after meals, at bedtime, and during night rounds. However, during the same night shift, the CNA failed to complete resident rounds or provide toileting and incontinence care. Subsequent checks revealed that both residents had heavily saturated incontinence products and urine‑soaked beds, and the second resident had redness and moisture‑associated skin damage in the buttock area, demonstrating that his scheduled toileting and hygiene interventions were not carried out as planned.
Borrowing Controlled Medication Between Residents in Violation of Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were delivered according to professional standards of quality when a controlled medication prescribed for one resident was taken and administered to another resident. On the night in question, a physician issued a new STAT order for Lorazepam 0.5 mg by mouth for a resident experiencing anxiety. The DON informed the physician that the ordered medication was not available in the facility for that resident, the distributing pharmacy was closed, and the resident’s family did not want the resident sent to the ER for evaluation. Despite this, the physician verbally instructed the DON that nurses were to borrow Lorazepam from another resident who had 0.5 mg Lorazepam tablets available in the facility. Following this instruction, the DON relayed to nursing staff that they were to use the other resident’s Lorazepam for the anxious resident when other comfort or distraction measures failed. An LPN subsequently removed a 0.5 mg Lorazepam tablet from the first resident’s medication card and administered it orally to the second resident. The medication was effective in relieving the second resident’s anxiety. The first resident’s controlled medication, which was ordered specifically for that resident, was therefore used for another resident, and the facility later arranged for the tablet to be replaced. Interviews with the administrator, DON, and consultant pharmacist confirmed that borrowing medications from one resident to administer to another is not acceptable clinical practice and does not meet professional standards of care. The administrator and DON acknowledged that the facility did not follow its own policies and procedures for medication ordering or resident treatment in this situation. Policy review showed that controlled substances are subject to special ordering, receipt, and recordkeeping requirements, and that when medications are not available, nursing staff are to notify the attending physician, explain the circumstances and available options, and obtain a new order while discontinuing the non-available medication. These established procedures were not followed when the staff borrowed one resident’s controlled medication and administered it to another resident.
Food Safety and Hand Hygiene Failures During Meal Preparation and Service
Penalty
Summary
The facility failed to ensure that dishware used to prepare and serve residents’ meals was sanitized according to standard food safety practices. Surveyors observed that the commercial dishwasher in the kitchen was not working, and dietary staff reported that dishes were being washed in a three-compartment sink with the third compartment used for sanitizing. During testing, the dietary manager used expired sanitizer test strips, and the solution in the sink did not change color to indicate proper sanitizer levels. The dietary manager also could not locate any other test strips to verify the sanitizer concentration. Surveyors further observed multiple food handling and sanitation practices that did not follow the facility’s procedures. A dietary manager was observed handling kitchen items and food without washing hands after removing gloves, drying hands on an apron, and using a washcloth from the dishwashing area to wipe a cart and counter. The same staff member handled chicken breasts, checked their temperature, washed a knife, and did not place it into sanitizer for the required time. A dietary aide was observed serving plated meals from a cart that had been cleaned with soap and bleach water, placing the plates back on that same cart, and serving them to residents. The report also documented that sanitizer checks were not consistently completed on the facility’s log over several months, and staff interviews confirmed that sanitizer levels were not always documented. Dietary staff were observed serving drinks and plated meals while wearing gloves that had already been used to handle carts, cups, plates, and food, including touching the rims of drinking glasses and the food on residents’ plates. The facility’s hand hygiene and employee hygiene policies required handwashing after removing gloves, before handling food, and during food preparation, but staff actions observed by surveyors did not follow those requirements.
Daily nursing staffing posting not readily visible or clearly labeled
Penalty
Summary
The provider failed to post the required daily nursing staffing information in a location readily visible to residents, staff, and visitors, and the information posted did not clearly reflect actual hours worked by nursing staff for 18 of 18 days reviewed for November 2025. On observation, the Staffing Census Sheet was posted on the wall beside a door labeled staff only behind the 400 hall nurses' station, approximately six feet off the floor. The form included the date and resident census, but the numbers entered under the RN, LPN, CMA, CNA, and Restorative/Activity Aide headings were not identified as to what they represented. The staffing sheet was only displayed in the 400 hallway and was not readily visible to residents or family members on the 300 hallway. A resident seated in a wheelchair stated the sheet was too high to read until it was lowered, and then said she was unsure what the numbers on the form meant. Staff stated the night nurse completed the sheet based on assignment sheets prepared by management, that leadership staff hours were not included, and that the numbers represented scheduled hours. Review of the staffing sheets showed entries indicating no RN on duty on multiple days, and the administrator later verified one of those entries was not accurate because both the administrator and DON were RN staff in the building and available to assist residents during the day shift. The administrator also agreed the sheet was not readily accessible to all residents, staff, and visitors, and that the numbers were not clearly identified.
Therapeutic diets not served in prescribed form
Penalty
Summary
The facility failed to ensure that nine sampled residents were served foods in the appropriate form according to their physician-ordered therapeutic diets. During observation, a dietary aide served whole chicken breasts, whole slices of ham, and cubed ham in approximately one-inch pieces, did not have resident diet cards available, and relied on memorized diets and a posted list. He stated that all mechanical soft residents were served cut-up ham, that no ground meat had been prepared, and that carrot cake was added to all meal plates, including those for residents ordered consistent carbohydrate diets. He also stated that for no-added-salt diets, salt was simply not added to the food. Additional observation showed that no residents had ground meat on their meal plates and that any cut-up meat was in approximately one-inch-sized pieces. One resident who required assistance with eating and had a mechanical soft diet was observed with a whole pork cutlet on the plate, along with other foods, even though staff stated they were to cut up his food and feed it to him. Another resident with no teeth stated she could not chew hard food but was given that type of food and did not eat all of her meals. A third resident with a mechanical soft, ground meat diet was observed being served a pork cutlet cut into pieces approximately one inch by one-half inch. Record review showed multiple residents had physician orders for mechanical soft, ground meat, regular texture with mechanical soft texture, renal/consistent carbohydrate, or consistent carbohydrate and no-added-salt diets. Several residents had dental problems, missing teeth, chewing difficulty, or care plans indicating the need for mechanical soft diets or staff assistance with eating. The dietary manager stated mechanical soft diets should be prepared in one-quarter-inch pieces with gravy to make them moist and agreed that one-inch meat pieces were too large for a resident requiring a mechanical soft diet. The registered dietitian stated mechanical soft diets were comparable to NDD3 and required meats cut into pieces smaller than one inch unless otherwise specified, and that the meat should be moist, tender, and easily mashed with a fork. The facility policy stated therapeutic diets are to be provided in the appropriate form as prescribed by the physician or delegated dietitian.
Care Plans Not Individualized for Mental Health and Pain Needs
Penalty
Summary
The facility failed to develop and maintain individualized care plans that reflected the current needs of three sampled residents. One resident with dementia, anxiety, and depression was observed crying in her room, stating she was tired of doing the same things, slept all the time, missed her children, and did not want to live anymore. She told staff she had spoken with them about not wanting to live anymore and then stated she should just try to kill herself. Her record showed a diagnosis of dementia, anxiety disorder, and depression, along with a physician order for fluoxetine after increased sadness and tearfulness were documented. However, her care plan only addressed dementia-related forgetfulness and psychotropic medication use and did not identify her tearfulness, suicidal statements, triggers for depression or anxiety, or nonpharmacological interventions. A second resident with schizophrenia was observed in his room and had a history of schizophrenia with long-term use of risperidone and behavioral health follow-up. Records showed episodes of resistance to care, including refusing to shower, turning away from staff, and becoming more resistant to doing things for himself while wanting staff to do everything for him. Behavioral health notes directed staff to document behaviors and nonpharmacological interventions and to monitor for hallucinations, daytime somnolence, falls, and return of symptoms. His care plan, however, only addressed psychotropic medication use and tobacco use, and did not identify his schizophrenia symptoms, refusal of self-care, mental health provider involvement, or interventions to use when behaviors occurred. A third resident had chronic foot pain and diabetic neuropathy. Her MDS indicated pain almost constantly and that pain made it hard for her to sleep almost constantly. Her record included multiple pain-related medication orders, including acetaminophen, muscle rub, and gabapentin. Despite this, her care plan did not include a pain focus area, a goal, or any pharmacological or nonpharmacological interventions for pain. Staff interviews confirmed they expected care plans to identify behaviors, triggers, and nonpharmacological interventions, and the MDS consultant and DON acknowledged that the residents' care plans had not been updated to include the relevant symptoms, behaviors, or pain interventions.
Bed Rail Assessments Lacked Alternatives and Required Review
Penalty
Summary
The facility failed to ensure that alternatives were attempted before side rails were used for ten sampled residents and failed to ensure that four sampled residents with side rails had a safe-use assessment completed within the last three months per facility policy. Observations showed multiple residents had quarter-length side rails in the up position on their beds, including residents 1, 2, 3, 7, 8, 14, 15, 17, and 20. Interviews with several residents showed they used the side rails to get in and out of bed, sit up in bed, or transfer, and some stated they had been educated about the risks and benefits when admitted, while others did not recall receiving education or consent discussions. Record review showed each of the cited residents had a physician order allowing positioning/assist bars if indicated after safety assessment, device assessment, and IDT review. However, the safety assessment forms for these residents did not document that alternatives had been attempted before the side rails were implemented. For residents 1, 2, 14, 15, 17, and 20, the assessments also had the risk section and/or signature section unchecked. Resident 14’s assessment noted two side rails on the bed, and resident 20 stated one rail was already present when he was admitted and he requested the second rail. Resident 15 had intact cognition by BIMS score 15 and said she used both rails to get out of bed depending on which side she used. For residents 3, 7, 8, and 17, the facility did not complete updated side rail assessments within the last three months according to its policy. Resident 3 had a BIMS score of 8 and a prior progress note documented she became agitated and put her arm through the siderail while staff were positioning her in bed. Resident 7 had a BIMS score of 4 and a guardian signed the assessment; resident 8 had a BIMS score of 11 with diagnoses or conditions including dementia, seizures, and visual impairment; and resident 17 had a BIMS score of 15 and stated she had not received education about the rails since admission. The DON confirmed that side rail assessments were to be completed on all residents upon admission and reviewed quarterly, and also confirmed that alternatives to side rails were not attempted prior to installation. The facility policy required documentation of attempted alternatives, informed consent, and review of risks and benefits before bed rail use.
Medication Room Temperature Not Monitored
Penalty
Summary
The facility failed to ensure temperatures were maintained within a proper temperature range for safe medication storage in its medication room. During observation and interview, the medication room was noted to feel significantly warmer than the hallway outside the room. Daily temperature readings were documented for the refrigerator and freezer on the side of the refrigerator, but there was no documentation of the medication room temperature itself. RN/staff development K pointed to a thermostat set at 72 degrees F but stated she did not know of any temperature monitoring or documentation for the medication room. Further interviews confirmed that the medication room temperature was not being monitored or documented. RN/IC C and LPN/restorative nurse N stated there was no temperature monitoring or documentation for the medication room to ensure it was in a safe medication storage range, and RN/IC C said the temperature had not been monitored in the five years she had worked at the facility. The DON stated the medication room often seemed warmer or cooler than the rest of the facility, but she was not aware that it had ever been checked to determine the actual temperature, and she was not aware the room was required to be maintained between 59 and 86 degrees F for safe storage of medications. The facility policy stated that medications and biologicals are stored in locked compartments under proper temperature, humidity, and light controls.
Infection Control Lapses During EBP Care, Transfers, Medication Administration, and Dressing Changes
Penalty
Summary
Infection prevention and control practices were not followed during direct resident care for a resident on enhanced barrier precautions (EBP) for a stage 3 sacral pressure ulcer and urinary catheter. The resident’s care plan required gowns and gloves for high-contact care activities, including repositioning and device care. During observation, two CNAs repositioned the resident while wearing gloves but without gowns, and one CNA emptied the resident’s urinary catheter without a gown while the resident had a catheter and sacral wound dressing in place. In another observed event, a resident with diagnoses including a chronic right lower leg ulcer, cellulitis, and a history of MRSA was on EBP for skin wounds. While wearing PPE, a nursing assistant removed the resident’s incontinence brief, completed personal hygiene, applied a new brief, and then used the same gloved hands to pull up the resident’s pants, place a lift sling, hook the sling to a total body lift, transfer the resident into a wheelchair, and push the resident in the wheelchair. The nursing assistant then pushed the lift into the hallway without cleaning it. The CNA involved stated she was not aware the lift needed to be cleaned after use and verified it was not cleaned after assisting the resident. Hand hygiene was also not performed during medication administration and dressing care. An LPN applicant did not perform hand hygiene before gathering supplies for an insulin administration, put on gloves without hand hygiene, touched the medication cart keyboard with gloved hands, administered insulin, and then applied alcohol-based hand sanitizer incorrectly after removing gloves. An RN/MDS/skin and wound nurse entered a resident’s room, applied PPE, and changed a foot dressing without performing hand hygiene before donning gloves, after removing dirty gloves, or before putting on clean gloves. The facility’s policies stated hand hygiene was the primary means to prevent infection, gloves did not replace hand hygiene, and hand hygiene was required before and after direct contact, after removing gloves, and before handling clean or soiled dressings.
Failure to Timely Report Allegations of Neglect from Resident Council
Penalty
Summary
A certified nursing assistant (CNA) who also served as activity staff attended and documented a resident council meeting where residents raised concerns about personal care, including issues such as residents appearing unkempt at meals and activities, exposure of body parts, and lack of privacy during care. These concerns were recorded as allegations of neglect in the meeting minutes. However, the CNA did not report these allegations to the administrator as required by facility policy, resulting in a delay in notifying the appropriate authorities. The administrator was not made aware of the allegations until five days after the meeting, and the South Dakota Department of Health (SD DOH) was notified six days after the initial allegations were made. Facility policies require that all allegations of abuse or neglect be reported to the administrator immediately, and to state authorities within 24 hours if there is no serious bodily injury. The failure to report the allegations in a timely manner led to noncompliance with both facility policy and regulatory requirements.
Failure to Address Resident Council Concerns About Loud TVs and Public Care
Penalty
Summary
The facility failed to respond to resident concerns raised in resident council meetings about nursing care being performed in public areas and televisions being kept loud at night. Residents reported that complaints heard by staff had no follow-through, and one resident stated the loud televisions were so bothersome that they made her physically sick. The resident council minutes showed repeated concerns over several months about televisions and radios being loud at night, staff taking vital signs, giving insulin injections, combing residents’ hair, and fixing residents’ clothing in shared common areas. Review of the grievance logs showed that the concerns were not consistently documented or addressed. A July grievance log did not list the loud televisions or radios, an August grievance log stated there were no problems or concerns, and a September grievance log addressed only part of the concern about residents not being presentable for meals by explaining that other residents had the right not to have their hair combed. It did not address adjusting clothing or combing hair in front of others. The November grievance log had not yet been completed at the time of review, despite the concern having been raised at the resident council meeting. Observations and interviews confirmed the concerns remained unresolved. A resident’s television was heard loudly from the hallway and from another resident’s room, and another resident reported difficulty sleeping because of the noise. Staff acknowledged that the loud television concern had been brought up in shift report, but no one had asked the resident to turn it down that day. The DON stated she had observed staff combing hair, performing blood glucose checks, and administering medications in the dining room, and the administrator acknowledged that providing resident care in the dining room and the loud television volume had not been addressed. The resident council policy required the facility department related to any issue to address concerns, and the grievance policies required prompt efforts to resolve grievances and immediate action to prevent further potential violations while allegations were investigated.
Inaccurate PASRR Screening for Resident With Schizophrenia
Penalty
Summary
The provider failed to ensure one sampled resident with schizophrenia had an accurate Level I PASRR evaluation after being identified as having a possible serious mental illness. The resident was admitted to the facility with a diagnosis of schizophrenia, had an intact BIMS score of 15, and had a physician order for Risperdal 1 mg three times daily. The record also showed a prior PASRR Level II from 2019 stating the diagnosis of mental illness was unsubstantiated because the resident’s current diagnoses did not include a serious mental illness, but later documentation in the chart identified schizophrenia as the diagnosis. Interview and record review showed the resident reported being diagnosed with schizophrenia about seven years earlier and had been seeing a mental health provider. The PASRR screening manager stated the September 2019 PASRR was unsubstantiated because the diagnosis at that time was unspecified mood disorder, and that a new PASRR should have been submitted when the diagnosis changed to schizophrenia on admission. Activity/social service staff responsible for PASRR referrals stated they were unaware the diagnosis had changed and therefore did not submit a Level II referral. The facility policy required the PASRR screening to be completed accurately before every admission and based on all available medical records.
Failure to Document Effectiveness and Adverse Reactions of Newly Ordered Fluoxetine
Penalty
Summary
The facility failed to document the effectiveness and adverse reactions of a newly ordered antidepressant, fluoxetine, for a resident with dementia, anxiety, and depression. The resident had a BIMS score of 8, indicating moderately impaired cognition, and was started on fluoxetine 10 mg daily for anxiety and depression after previously being changed from sertraline because she had become more tearful. The record showed only one nursing progress note after the medication was started, and that note stated the resident was pleasant and cooperative with no behaviors noted that shift. During observations, the resident was repeatedly seen resting with her eyes closed, and on interview she stated she was tired of doing the same things, slept all the time, missed her children, and did not want to live anymore. She cried during the interview and stated she should just try to kill herself. The DON verified that the resident’s statements about wanting to die had not been documented in the EMR, that there was no consistent documentation of tearfulness before the medication change, and that there was only one nurse progress note after fluoxetine was started. The DON also agreed there was no documented resident complaint, symptom, or behavior identified as the intended use for Prozac, so the effectiveness of the medication could not be determined from the record. The facility’s hot charting form listed the resident and fluoxetine for monitoring over three days, and the administrator and MDS consultant confirmed newly ordered psychotropic medications were expected to be reviewed and monitored for adverse effects and effectiveness during the first 72 hours. However, they verified there was only one nursing progress note in that period and no documentation by social services related to the effectiveness of the fluoxetine during the resident’s first month of use. The DON further verified adverse reactions were not being monitored or documented on the resident’s TAR as they were for other residents on psychotropic medications.
Uncertified Dietary Manager
Penalty
Summary
The dietary manager was not certified according to the requirements. During interview, the dietary manager stated she had been hired as the dietary manager in 2013 and was not a certified dietary manager. She reported that the registered dietitian had encouraged her to take the certified dietary manager course, and that she had registered for the course a year earlier but was unable to complete it because of a personal situation. The administrator confirmed the dietary manager had been hired in 2013, was not certified, and was currently enrolled in a dietary manager certification course. Review of the dietary manager’s employee file showed no documentation that she had taken a dietary manager course in the past.
Medical Director Did Not Attend QA Meetings Quarterly
Penalty
Summary
The provider failed to ensure the Medical Director attended and meaningfully participated in the Quality Assurance (QA) meetings at least quarterly. During an interview with the administrator and MDS consultant, it was reported that QA meetings were held every four to five weeks in person and through Zoom, and that the QA committee included the maintenance supervisor, DON, administrator, MDS consultant, MDS coordinator, staff development, infection control preventionist, restorative nurse, and Medical Director. However, the Medical Director did not attend the meetings in person or through Zoom on a quarterly basis and instead was provided information after the meetings. Review of the provider’s 2024 QA policy showed that identified problems were to be addressed and prioritized, but the policy did not identify the QA committee members or how often they were required to attend.
Failure to Implement Antibiotic Stewardship Monitoring Program
Penalty
Summary
The provider failed to develop and implement an effective antibiotic stewardship program to monitor appropriate antibiotic use according to its own policy. The 2024 Antibiotic Stewardship Program policy required antibiotic use protocols, monitoring of response to antibiotics within 48-72 hours, review of laboratory results, random audits of antibiotic prescriptions, tracking of at least one monthly outcome measure, review of the antibiogram every 18-24 months, and written feedback reports and documentation related to the program. The September 2017 Surveillance for Infections policy also required nursing staff to monitor residents for signs and symptoms of infection, analyze data for trends, and provide surveillance data to the Infection Control Committee regularly. During interview and record review, the RN/IC stated she was new to the infection control and antibiotic stewardship role, and the LPN/restorative nurse had previously overseen the program. The antibiotic stewardship binder contained only a monthly breakdown of physician orders for antibiotics and an annual listing of antibiotics ordered for each resident. Staff stated they used McGeer criteria to identify potential infections, but there was no written documentation showing that McGeer criteria were used when staff suspected a resident had an infection before notifying the DON or practitioner. Staff also stated they used common knowledge to determine when a resident with suspected UTI symptoms met criteria for urinalysis, rather than following specific criteria. The DON stated nursing staff completed an assessment and called the DON, who then contacted the medical director for orders, but there was no written form for staff to use to determine whether criteria were met for a lab or antibiotic request. Nursing did not review antibiotics for effectiveness 48-72 hours after initiation, and culture reports were not reviewed by nursing during an antibiotic timeout. The DON also stated there was no documentation of infection trends, no antibiogram use, no tracing of clusters, no written action plan or work plan, no assessment forms, no antibiotic use protocols, no data collection forms, no feedback reports or annual reports beyond the antibiotic listings, and no records of education provided to physicians, residents, or families related to antibiotic stewardship.
Failure to Provide Well-Balanced Diet and Consistent Meal Portions
Penalty
Summary
The facility failed to provide a well-balanced diet that considered the food preferences and dietary needs of its residents. Three residents expressed dissatisfaction with the meals provided, noting that they were not given choices or menus to select from, and if they refused the meal, they were only offered soup. One resident, who required a mechanical soft diet, received hard fruit, while another resident with diabetes and a consistent carbohydrate diet expressed dissatisfaction with the lack of meal options. The facility did not have an alternative menu, and residents were not consistently offered alternate meal options if they did not like what was served. The facility also failed to ensure that food portions were measured and consistent. During meal preparation, a CNA, who was not part of the regular kitchen staff, did not use measuring utensils to portion ham salad sandwiches, cucumbers with ranch, and three-bean salad. This inconsistency in portion sizes was attributed to short staffing and the CNA's nervousness due to the presence of surveyors. The dietary manager acknowledged the lack of an alternate meal and the absence of consistent portion sizes. The registered dietician, who was a contracted employee, did not visit the facility and was not informed of menu substitutions, which were made regularly due to food availability and resident preferences. The facility administrator acknowledged the staffing challenges and the need for documentation and dietician approval of substitutions. The facility's policy required residents to receive meals according to their needs and preferences, but this was not consistently followed, leading to the deficiency.
Failure to Submit PBJ Data on Time
Penalty
Summary
The provider failed to submit their Payroll Based Journal (PBJ) data for Quarter 1, 2024, to the Center for Medicare and Medicaid Services (CMS) as required. The review of the Certification and Survey Provider Enhanced Reports (CASPER) data revealed that no PBJ data was submitted for the period from October 1, 2023, through December 31, 2023. This deficiency was identified during an interview with the facility's administrator, who acknowledged the requirement to submit the data and the existence of deadlines. The administrator indicated that a vendor was responsible for tracking payroll and PBJ data, but the vendor missed the submission deadline. Further interviews with the administrator and the outsourced chief financial officer (CFO) revealed that the CFO's office was responsible for ensuring the PBJ data was submitted to CMS. A staff member from the CFO's office failed to submit the data by the deadline, missing it by one day. Both the administrator and the CFO expected the data to be submitted on time each quarter. The facility's policy, revised on January 4, 2023, stated that it is their policy to submit complete and accurate staffing information to CMS in a timely manner, but this was not adhered to for the specified quarter.
Failure to Timely Report Incidents to SD DOH
Penalty
Summary
The provider failed to provide timely and thorough notification to the South Dakota Department of Health (SD DOH) regarding incidents involving two residents. Resident 2 reported hearing a pop in her knee during a transfer, which was not immediately documented in the nurse's progress notes. Despite experiencing significant pain and swelling, the resident was not sent to the emergency room until two days later, and this information was omitted from the facility's initial and final reports to the SD DOH. The resident was eventually diagnosed with a proximal right tibial fracture, but the details of her hospital visit and diagnosis were not included in the final report. Resident 6 experienced an unwitnessed fall and was found sitting on the floor. Although she reported pain and requested medical attention, there was no immediate documentation of the fall in the nurse's progress notes. The resident's family requested an x-ray due to her complaints of pain, leading to her transfer to the emergency room. However, this information was not included in the initial report submitted to the SD DOH, and the final report was not submitted on time. The Director of Nursing (DON) admitted to not reporting the incidents in a timely manner, citing a lack of information and falling behind in reporting duties. The facility's policy requires immediate notification of the administrator and reporting to the SD DOH within two hours of forming a reasonable suspicion of a crime or injury of unknown source. The DON acknowledged awareness of these guidelines but failed to adhere to them, resulting in incomplete and delayed reporting of the incidents involving residents 2 and 6.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as prescribed by physicians for 16 out of 21 residents. Observations revealed that meals served did not align with the approved scheduled menu items, and there was no documentation or approval from the dietician for these substitutions. All residents received the same meal without differentiation between their individually prescribed diets, which included regular, heart healthy, renal, consistent carbohydrate, and no added salt diets. The dietary manager admitted to making substitutions due to the unavailability of menu items and personal preferences of the residents, without notifying or obtaining approval from the dietician. Interviews with the registered dietician and the facility administrator confirmed that the kitchen staff did not follow the approved menus and failed to document substitutions. The dietician expressed concerns about not being informed of menu changes, and the administrator acknowledged challenges in adhering to prescribed diets due to resident preferences and complaints from elderly protection. A review of dietary orders showed that specific dietary needs were not addressed for several residents, including those requiring consistent carbohydrate, heart healthy, no added salt, and renal diets.
Failure to Implement Enhanced Barrier Precautions for Residents with Open Wounds
Penalty
Summary
The provider failed to ensure that two residents with open wounds were placed on enhanced barrier precautions (EBP). Observations revealed that staff members did not wear gowns or gloves when entering the room of a resident who required the use of a Hoyer lift for transfers. Despite the presence of a sign indicating the need for EBP and available supplies, these were not visible when the door was open. Interviews with the resident and a certified nursing assistant (CNA) confirmed that gowns and gloves were not used during transfers. The resident's electronic medical record indicated a dressing for a chronic ulcer on the right leg. Another resident with an open wound on the left foot also did not have EBP signage or supplies near the door. Staff members did not wear gowns during transfers or while providing wound care, although gloves were used during bandage changes. Interviews with a licensed practical nurse (LPN) revealed a lack of knowledge about the facility's EBP policy, with the LPN believing that EBP was only necessary for residents with multi-drug resistant organisms (MDROs). The infection control registered nurse (ICRN) also indicated that EBP was only expected for wounds with MDROs or uncontainable seepage, contrary to the facility's policy that required EBP for all residents with wounds.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The provider failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospital transfers of a resident, identified as resident 13. The resident was transferred to the hospital on two occasions, once on January 29, 2024, and again on September 11, 2024. In both instances, while the resident's power of attorney (POA) was informed of the transfers, there was no documentation indicating that bed hold information was provided to either the resident or the POA. Furthermore, the facility did not send a copy of the transfer notice to the Ombudsman as required by regulations. Interviews with the facility's social services staff revealed a lack of awareness regarding the requirement to notify the Ombudsman of every hospital transfer. The social services department, responsible for these notifications, admitted to sometimes using email or phone calls for communication but did not consistently follow the protocol. The local Ombudsman confirmed not receiving notifications for the resident's transfers and had previously discussed the regulation with the facility's social services staff. Despite this, no documentation was available to verify that the Ombudsman was informed of the transfers, indicating a failure in the facility's notification process.
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 continued use beyond the 14-day limit. The resident had a physician's order for lorazepam to be administered every four hours as needed for increased anxiety and tooth pain. Despite the facility's policy requiring PRN orders for psychotropic medications to be renewed every 14 days, the order was not renewed, and the medication was administered 21 times from August 15 to September 30. The physician's response to extend the PRN order indefinitely was not documented until September 30, and the director of nursing signed it on October 2, indicating a lapse in compliance with the policy. Interviews with the director of nursing and a restorative LPN revealed that they were aware of the requirement for PRN lorazepam orders to be renewed every 14 days but were not aware that the order had not been renewed. The facility's policy on psychotropic medication use emphasizes the need for gradual dose reductions and limits PRN orders to 14 days unless a prescriber documents the rationale for extending the order. The failure to renew the PRN lorazepam order as required by policy resulted in a deficiency in the facility's medication management practices.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that a resident received food prepared to the correct temperature, as observed during a survey. The kitchen warming cabinet's thermometer was not functioning, and the temperature control dial was set at varying levels, which were not verified for accuracy. The dietary manager and cook both prepared pureed meals for the resident using warm broth, but did not recheck or reheat the food to ensure it was at a safe temperature before serving. The temperatures of the pureed foods were recorded to be below the required 135 degrees Fahrenheit, with some items as low as 107.9 degrees Fahrenheit. The facility's food preparation and service policy was not followed, as the danger zone for food temperatures was not avoided, and there was no internal thermometer in the warming cabinet to ensure safe food temperatures. The maintenance department was aware of the broken thermometer for two to three months, but a new warming cabinet was only ordered recently. The administrator was also recently informed of the issue and expected the facility's policies to be adhered to. The facility's food temperature log showed that while cooked food temperatures were documented after cooking, there was no record of temperatures being checked after pureeing and before serving.
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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.
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