Palisade Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garretson, South Dakota.
- Location
- 920 4th St, Garretson, South Dakota 57030
- CMS Provider Number
- 435115
- Inspections on file
- 24
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Palisade Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and a history of pressure ulcers developed new wounds on the lower legs and foot. Staff failed to promptly assess, document, and communicate these wounds, leading to delays in treatment and a lack of timely interventions. Inaccurate information was sent to the physician, and several days passed without care for the wounds, resulting in the resident's condition worsening and requiring hospitalization. Facility policies for skin integrity monitoring and response were not followed, contributing to the deficiency.
A resident with quadriplegia and a prior cervical spine fracture was injured during a transfer when an LPN and a CMA/CNA used an incorrectly sized full-body lift sling, resulting in a fall and a hematoma. Staff used multiple brands of slings but relied on a single sizing chart, disregarding manufacturer-specific sizing requirements. The facility lacked policies for assessing and documenting appropriate sling size, and several residents were observed using slings of undetermined or potentially incorrect sizes.
Two residents at risk for pressure ulcers did not receive timely or adequate preventive interventions, resulting in the development of new pressure ulcers. In both cases, required measures such as heel boots, pressure-reducing mattresses, and frequent repositioning were either delayed, inconsistently applied, or not documented as performed. Staff interviews and record reviews confirmed that care plans and facility policies for skin integrity were not followed prior to the onset of the ulcers.
Multiple residents experienced significant delays in call light response, with some waiting up to two hours for assistance. Audit data and interviews confirmed that staff did not consistently meet the expected response time of three to five minutes, and residents with high care needs were particularly affected. The facility lacked a formal call light response policy, and both resident council minutes and grievances documented ongoing concerns about long wait times and short staffing.
Drugs and biologicals were not labeled in accordance with professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Multiple residents reported that meals were frequently served cold, especially to those eating in their rooms or served last in the dining room. Food was often unappetizing, and menu substitutions were common due to shortages, with residents not consistently receiving updated menus. Staff confirmed that menu distribution had stopped, and observations showed food temperatures below policy standards. Resident council minutes and grievances documented ongoing dissatisfaction with food quality, service delays, and lack of communication about meal options.
Staff failed to consistently perform hand hygiene, use gloves and gowns, and follow contact and enhanced barrier precautions during resident care, including wound care and care for residents with C. difficile and pressure ulcers. Clean supply fields were contaminated, mechanical lifts were not sanitized between uses, and hand hygiene supplies were often unavailable or nonfunctional in resident rooms and bathrooms. Staff were sometimes unaware of proper protocols or the location of PPE, and housekeeping did not routinely check or refill hygiene supplies.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required.
The facility failed to provide required Medicare notices using the current forms and did not ensure proper completion and documentation for two residents discharged from Medicare Part A skilled services. One resident received an outdated NOMNC form missing the non-discrimination clause, while another's NOMNC was unsigned and undated, and the SNF ABN lacked a specific explanation and provider identification for verbal notification.
A resident with dementia and other conditions fell from his wheelchair due to unlocked brakes, resulting in a head laceration. The facility failed to update his care plan to include an anti-roll back bracket intervention, despite a maintenance ticket being placed. The resident was later found in the wrong chair, and the intervention was missed in the care plan update.
A resident with cognitive impairments fell and sustained a head injury when attempting to self-transfer from a wheelchair lacking an anti-roll back bracket. The facility failed to ensure the resident's safety by not updating the care plan to include this intervention, and the resident was found using a different wheelchair without the necessary safety feature.
A resident with psoriasis did not receive physician-ordered leg care, despite documentation by an LPN indicating otherwise. Family members discovered poor hygiene, saturated socks, and maggots on the resident's feet. Assessment by the DON and wound nurse confirmed untreated skin issues and improper care, including the use of vinegar not ordered by a physician. These actions and omissions constituted neglect as defined by facility policy.
A resident with multiple chronic conditions and physician-ordered skin treatments did not have their care plan updated to reflect specific orders for daily dressing changes and compression wraps. Although detailed orders and assessments were present in the medical record, the care plan only included general skin care interventions and omitted the individualized treatments prescribed by the physician. Staff interviews confirmed the absence of a formal care plan policy and that updates were not consistently made.
A CMA failed to administer Sevelamer HCL according to pharmacy directions for a resident with end-stage renal disease. Despite a label indicating not to crush, the CMA crushed the medication and mixed it with applesauce, leaving the resident before ensuring ingestion. The DON was unaware of this practice, which was against facility policy.
Failure to Timely Assess, Document, and Treat Skin Injuries Resulting in Hospitalization
Penalty
Summary
The facility failed to provide quality care in the prevention and management of skin injuries for a resident with significant medical complexities, including chronic heart failure, peripheral vascular disease, malnutrition, and Brown-Sequard syndrome. The resident was dependent on staff for repositioning and transfers, and had a history of pressure ulcers, including an unstageable ulcer on the coccyx. Despite having a care plan and physician orders in place for regular skin assessments and wound care, staff did not consistently evaluate, document, or communicate changes in the resident's skin condition, particularly regarding new wounds on the left lower leg, left foot, and right lower leg. Multiple breakdowns in communication and documentation were identified. When new wounds were first observed, the responsible nurse did not complete a skin evaluation or document the findings, and there was confusion regarding the correct location of the wounds in communications with the physician. Treatment orders were delayed and not implemented promptly, and there were several days where no interventions were provided for the resident's leg wounds. Staff interviews revealed uncertainty about documentation procedures and a reliance on the wound care nurse to address new skin issues, rather than immediate action by the nurse who identified the problem. The lack of timely assessment, accurate documentation, and prompt intervention resulted in the resident's wounds worsening, ultimately requiring hospitalization. The facility's own policies required daily skin inspections, prompt reporting of changes, and immediate implementation of interventions for new or worsening wounds, but these procedures were not followed. The failures in evaluation, communication, and treatment placed the resident at risk for serious harm and led to the identification of an Immediate Jeopardy situation by surveyors.
Failure to Ensure Safe Mechanical Lift Transfers Due to Improper Sling Sizing and Lack of Assessment
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, a history of cervical spine fracture, and other complex medical conditions was transferred using a full-body mechanical lift and an incorrectly sized sling. During the transfer, the resident fell from the sling, striking her head on the floor and sustaining a hematoma behind her left ear. The staff involved, an LPN and a CMA/CNA, reported that all four sling straps were attached, but the sling slipped or became unhooked, resulting in the fall. The resident required hospital evaluation and imaging, which confirmed the hematoma but no acute fracture. The facility failed to ensure that sling sizes were properly assigned and used according to the manufacturer's instructions. Multiple brands and sizes of slings were in use, but staff relied on a single sizing chart (EZWay) for all brands, despite each manufacturer having different sizing criteria. For example, the Guldmann brand required three body measurements, not just weight, to determine the correct size, but these measurements were not performed. Observations and interviews revealed that staff were unaware of the differences in sizing guides and often selected slings based on availability or assumptions rather than proper assessment. Additionally, the facility lacked policies and procedures for assessing residents for mechanical lift use, determining appropriate sling size, and documenting this information in care plans. There was no clear assignment of responsibility for these assessments, and therapy staff did not evaluate residents for sling size. As a result, several residents were observed using slings of undetermined or potentially incorrect sizes, and staff could not confirm the appropriateness of the slings in use. The absence of standardized assessment and documentation contributed to the unsafe transfer and subsequent injury.
Failure to Implement Timely Pressure Ulcer Prevention and Intervention
Penalty
Summary
The facility failed to adequately identify and implement pressure ulcer prevention interventions for two residents who were at risk for developing pressure ulcers. One resident, who was non-ambulatory and had severe cognitive impairment, developed a pressure ulcer on her heel. Prior to the ulcer's identification, the resident had complained of heel pain, but heel protectors were not provided until after the skin breakdown was noted. Documentation showed that interventions such as heel boots and an air mattress were only added to the care plan after the ulcer developed. Additionally, there was no documentation that the resident’s representative was notified of the change in her condition, and the wound nurse included interventions in the clinical review that were not in place prior to the ulcer’s development. Another resident, who had a history of pressure ulcers and was at moderate risk according to the Braden Scale, developed a new pressure ulcer on her coccyx. Observations revealed that her heel boots were not in use as required, and she was often found lying on her back despite having a pressure ulcer in that area. The care plan indicated she needed a pressure-reducing mattress, but she was observed with a standard mattress. Staff interviews confirmed that repositioning was not performed as frequently as required, and documentation showed the resident was only repositioned one to three times per day, rather than every two to three hours as expected. The resident herself reported that staff did not reposition her and that she would have preferred more frequent repositioning. The facility’s own policy required timely risk assessments, implementation of individualized interventions, and prompt notification of changes in skin condition to the physician and resident representative. However, in both cases, interventions were either delayed or not implemented as planned, and documentation was incomplete or inaccurate. The clinical reviews to determine whether the ulcers were avoidable were not completed within the expected timeframe, and in one case, the review was left blank until after the deficiency was identified.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to residents' call lights, resulting in multiple instances where residents waited extended periods for assistance. Observations and interviews revealed that several residents experienced significant delays, with one resident reporting waits of up to two hours and another stating they had to wheel themselves into the hallway and call out for help. Call light audit data confirmed numerous occasions where response times exceeded 15 minutes, with some instances surpassing an hour. These delays were corroborated by both resident interviews and electronic call light system records. Residents affected by these delays included individuals with significant care needs, such as a quadriplegic resident requiring assistance for all mobility and transfers, and another resident with a history of falls and incontinence who reported wetting herself due to long waits. The call light system audit showed repeated 'needs improvement' flags for response times in multiple rooms. Residents expressed feelings of degradation, abandonment, and distress due to the lack of timely assistance, and some had documented pressure ulcers or other conditions that made prompt response critical. Staff interviews indicated that the expectation was for call lights to be answered within three to five minutes, but this standard was not consistently met, especially after meal times or when staffing was low. There was confusion among staff regarding who was responsible for answering call lights, and the facility lacked a formal policy on call light response. Resident council meeting minutes and grievance records further documented ongoing concerns about long call light response times and perceived short staffing, indicating a persistent issue affecting resident care and satisfaction.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications within the facility.
Deficient Food Service: Cold Meals, Inaccurate Menus, and Poor Communication
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature, as well as to provide accurate menus to residents. Multiple residents reported dissatisfaction with the quality, temperature, and organization of meal service. Several residents stated that their meals were often cold, particularly those who ate in their rooms or were served last in the dining room. Observations confirmed that meal trays were delivered on uninsulated carts and sometimes left in hallways before being distributed, contributing to food being served at suboptimal temperatures. A test tray delivered to surveyors showed food items below the recommended hot holding temperature, with potatoes at 132°F and pulled pork at 135°F, both described as cool to the touch and unappetizing. Residents also reported that menus were not consistently provided, making it difficult for them to know what meals would be served or to make alternate choices. Staff interviews confirmed that menu distribution had ceased since a new contracted food service company began operations, and residents now had to request menus from the dietary manager. Menu substitutions were frequent and often due to shortages or delivery issues, with documentation sometimes incomplete or missing. Residents expressed frustration with these changes, noting that the food served often did not match the posted or distributed menus, and that substitutions were not always communicated in advance. Resident council meeting minutes and grievance records further documented ongoing complaints about food quality, service delays, lack of condiments, and insufficient communication regarding meal options. Some residents were unaware they could request alternate meals or were not asked about their food preferences, despite care plans indicating the need to monitor intake and offer substitutes if necessary. The facility's own policies required food temperatures to be monitored and corrective action taken if standards were not met, but observations and records indicated these procedures were not consistently followed.
Failure to Follow Infection Prevention and Control Protocols
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices among staff members during resident care. Staff, including CNAs, LPNs, RNs, and housekeeping, were observed not performing proper hand hygiene, not using gloves and gowns as required, and contaminating clean supply fields during wound care. For example, during wound care for a resident with open wounds, staff failed to change gloves and perform hand hygiene between tasks, touched clean supplies with soiled gloves, and placed potentially contaminated items back into shared storage. Staff also failed to follow contact precaution protocols for residents with infectious conditions such as Clostridium difficile, including not wearing required personal protective equipment (PPE) and not performing hand hygiene before and after resident contact. Several residents with significant medical needs, such as those with stage IV pressure ulcers, C. difficile infections, and indwelling medical devices, were not provided care in accordance with established infection control policies. Staff did not consistently use gowns and gloves during high-contact care activities, such as transferring, dressing, and providing hygiene to residents on enhanced barrier precautions (EBP). In some cases, staff were unsure of the requirements for EBP or the location of necessary PPE, and there were instances where mechanical lifts were not sanitized between uses for different residents. The facility also failed to ensure that hand hygiene supplies, such as alcohol-based hand sanitizer (ABHS) and soap, were readily available and functional in resident rooms and bathrooms. Multiple rooms lacked ABHS dispensers or had dispensers that were empty or nonfunctional, and some rooms lacked soap. Housekeeping staff did not routinely check or refill these supplies, despite this being a stated responsibility. Facility policies required accessible hand hygiene products and outlined specific hand hygiene moments, but these were not consistently followed by staff during the survey period.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documentation showing that the investigation outcomes were shared with the appropriate external agencies. No additional details about the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Deficient Medicare Notice Practices and Incomplete Documentation
Penalty
Summary
The facility failed to provide proper Medicare notices to residents who were discharged from Medicare Part A skilled services and remained in the facility. For one resident, the Notice of Medicare Non-Coverage (NOMNC) form used was outdated and did not include the required non-discrimination clause. This was confirmed by the MDS/RN coordinator, who acknowledged the form was not current. For another resident, the NOMNC form was not signed or dated by the resident or their representative, as required by the form's instructions. Additionally, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for the same resident did not include a sufficient explanation in the "Reason Medicare May Not Pay" section, only stating "Custodial Care" without specifying the Medicare services being denied. There was also no documentation of who provided the verbal notification to the resident's representative. The MDS coordinator confirmed these omissions and was unable to identify who had given the verbal notice. Review of the relevant CMS form instructions confirmed that these elements were required for compliance.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The provider failed to update a resident's care plan to reflect his current needs regarding fall intervention after an incident where the resident fell from his wheelchair and sustained a head laceration. The resident, who had a history of dementia, diabetes, memory deficit, delirium, cerebral infarction, and psychosis disorder with hallucinations, was known to self-transfer and was forgetful. On the day of the incident, the resident attempted to self-transfer from his wheelchair, which had unlocked brakes, resulting in a fall that required hospital evaluation and stitches. Although a maintenance ticket was placed to add an anti-roll back bracket to the wheelchair, this intervention was not included in the resident's care plan. The director of nursing (DON) later discovered that the resident was sitting in the incorrect chair, and his wheelchair was found in another resident's room. The DON acknowledged that the intervention to add an anti-roll back bracket had been missed in the care plan update. The facility did not have a specific care plan policy to review, and the licensed nurse responsible for updating care plans failed to include the necessary intervention to prevent future falls. The facility's Fall Management and Neurological check policy required care plans to be updated after a fall, but this was not adhered to in this case.
Resident Falls Due to Inadequate Wheelchair Safety Measures
Penalty
Summary
A resident in a South Dakota nursing home experienced a fall resulting in a head laceration that required hospital treatment. The incident occurred when the resident attempted to self-transfer from a wheelchair that lacked an anti-roll back bracket, causing the wheelchair to roll backward. The resident, who had a history of dementia, memory deficits, and other cognitive impairments, was known to self-transfer and was forgetful. The facility's investigation revealed that the wheelchair brakes were not locked at the time of the fall, and a maintenance request had been made to add an anti-roll back bracket to the resident's wheelchair. Observations and interviews conducted after the incident showed that the resident was using a different wheelchair without the necessary anti-roll back bracket, indicating a failure to ensure the resident's safety as per the care plan. The care plan, which was supposed to include the anti-roll back bracket intervention, was not updated accordingly. The Director of Nursing acknowledged that the resident's wheelchair was found in another resident's room, and the intervention had been missed in the care plan update. The facility's fall management policy required care plans to be updated after falls, but this was not adequately followed in this case.
Failure to Provide Physician-Ordered Skin Care Resulting in Neglect
Penalty
Summary
A resident with a diagnosis of psoriasis was not provided with physician-ordered care for his lower extremities. The resident had orders for Aquaphor ointment to be applied to his legs every shift due to dry skin associated with psoriasis. Despite documentation in the electronic medical record indicating that this treatment was completed, interviews and assessments revealed that the care was not provided as ordered. The resident reported that the treatment had not been done for several days, and the nurse responsible admitted to not performing the care, despite documenting otherwise. Family members visiting the resident observed and reported significant care concerns, including a foul odor in the room, dirty and saturated socks, and the presence of maggots on the resident's feet. Photographic evidence provided by the family confirmed the presence of maggots and poor hygiene. Upon assessment by the DON and wound nurse, the resident's legs were found to be reddened, edematous, and covered with patches of dry skin, with socks saturated from leg drainage. There was no evidence that the ordered treatment had been provided prior to this assessment. Further investigation revealed that the nurse had used vinegar to wash the resident's legs, which was not part of the physician's orders. The use of vinegar was only discontinued after a new physician's order was obtained in response to family concerns. The facility's policy defines neglect as the failure to provide necessary goods or services to avoid physical harm, pain, or emotional distress, and the actions and inactions of the staff in this case met that definition.
Care Plan Failed to Reflect Physician-Ordered Skin Treatments
Penalty
Summary
The facility failed to ensure that the care plan accurately reflected the current individualized care needs for a resident with physician-ordered skin treatments. The resident had multiple diagnoses, including psoriasis, vascular dementia, diabetes, peripheral vascular disease, chronic kidney disease, bipolar disorder, and localized edema, and was cognitively intact. Physician orders were in place for daily skin care to the lower extremities, including specific instructions for washing, drying, applying ointments, and using dressings and compression wraps. These orders were updated as treatments changed, such as discontinuing Aquaphor and starting Vaseline. Weekly skin observations were documented, and behavior charting noted refusals of care. Despite these detailed physician orders and ongoing assessments, the resident's care plan did not include the updated or specific interventions ordered by the physician, such as the daily dressing changes and use of compression wraps. The care plan only referenced general skin care interventions like barrier cream, lotion, and pressure-relieving devices, and did not reflect the physician's orders from 10/31/24 or subsequent changes. Interviews with facility staff revealed there was no formal care plan policy, and updates to care plans were made by the DON or RCM/LPN as needed, but the required changes for this resident's skin care were not incorporated into the care plan.
Medication Administration Error with Sevelamer
Penalty
Summary
The provider failed to ensure that a certified medication aide (CMA) administered medication according to pharmacy directions for a resident with end-stage renal disease and other disorders of phosphorus metabolism. The resident was prescribed Sevelamer HCL to control high phosphorus levels due to his dependence on dialysis. Despite a physician's order to crush all medications in applesauce, the CMA crushed Sevelamer, which had a label indicating it should not be crushed. The CMA removed the coating from the crushed tablets and mixed the remaining powder with applesauce, but did not ensure the resident swallowed the medication before leaving the room. The facility had a standing order to crush medications in applesauce, but no audits were conducted to ensure compliance with medication administration. The director of nursing (DON) was unaware that Sevelamer was being crushed, which was considered a significant medication error. The facility's policy stated that medications should be administered as prescribed and in accordance with manufacturer's specifications, and that personnel should familiarize themselves with the medication before administration. The policy also emphasized that medications with labels indicating they should not be crushed should not be altered, and residents should be observed to ensure the medication is ingested.
Latest citations in South Dakota
Two residents experienced failures in timely implementation of physician orders and provider notification. One resident with cognitive impairment, respiratory failure, pneumonia, and a urinary catheter had a UA/UC ordered after increased confusion, but catheter change and urine collection were delayed and inconsistent, and an antibiotic order faxed for a UTI was left on a reception fax machine and never started before a later order changed therapy based on culture results. Lab reports showing Enterobacter cloacae and susceptibility to a different antibiotic were not consistently documented as reviewed, and the resident continued to exhibit confusion and flank pain until transfer to the ER. Another resident with ESRD on dialysis, hypotension, hypertension, and heart failure had orders for Midodrine with BP parameters and daily Metoprolol, but Midodrine was not given on dialysis mornings and Metoprolol was rarely given on dialysis days, without notifying the physician. Very low BPs were recorded without documented provider notification or repeat checks, despite a TAR requiring monitoring for post-dialysis complications. Interviews and policy review showed expectations to follow orders and notify physicians of abnormal labs, omitted medications, and changes in condition, which were not met in these cases.
Two residents at high risk for pressure ulcers did not receive consistent, individualized prevention and treatment measures, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment and high Braden risk, fully dependent on staff for mobility and hygiene, was repeatedly observed in bed with the head of bed elevated and sliding down, without documented q2h repositioning, individualized pressure-relief interventions, or consistent use of barrier cream, and CNAs and restorative staff were unaware of specific pressure-prevention measures for her. Another resident with multiple comorbidities, prior healed pressure ulcers, and a high Braden score developed recurrent stage II and III pressure ulcers to the coccyx and gluteal fold, a left heel DTI, and a left lateral leg stage II ulcer; ordered wound treatments were not documented as completed on at least one ordered date, he was not on a defined turning schedule despite being largely bedfast, and heel offloading and use of heel boots were inconsistently implemented and documented. In both cases, staff interviews and record review showed that facility practices did not consistently align with the facility’s own skin and pressure injury prevention policy requiring q2h repositioning, appropriate support surfaces, and systematic offloading for bedfast residents.
The deficiency centers on unsafe resident transfers and unsecured chemicals. A resident with hemiplegia and severe cognitive impairment, care planned for a one-person sit-to-stand (STS) lift transfer, was instead manually transferred by a CNA without the lift, during which the resident’s legs gave out, he was lowered to the floor, hit his head, and later was found to have a subdural hematoma. Another resident with severe cognitive impairment and documented inability to meet STS criteria was nonetheless assessed and care planned for STS transfers, while staff and family intermittently pivot transferred her without a gait belt and with inconsistent use of mechanical lifts, amid reports that pocket care plans and Kardex information were not kept up to date. Additionally, surveyors repeatedly observed an open tub room with unlabeled and labeled chemical spray bottles accessible on the tub, and an unattended housekeeping cart in the dining room with toilet bowl cleaner and other disinfectants unlocked and reachable by residents, contrary to staff statements that such rooms and chemicals were to be secured.
The facility failed to consistently honor resident preferences and care‑planned frequency for bathing, resulting in multiple residents going six to ten days or longer between baths despite being scheduled for twice‑weekly showers or baths. Several residents, including those with impaired and intact cognition, reported missed or inconsistent baths, needing to repeatedly remind CNAs, and being told they were skipped due to other residents waiting longer, staffing shortages, or equipment issues. Observations included a resident with long, jagged fingernails and urine odor who reported missed scheduled showers. Review of EMRs and the bath schedule showed numerous missed baths without documented refusals or valid reasons, while the grievance log and resident council minutes documented ongoing complaints from multiple residents about not receiving baths as scheduled. Nursing staff acknowledged receiving complaints and that residents sometimes went more than a week without bathing, despite a facility policy stating residents have the right to choose timing and frequency of bathing and requiring documentation of bathing activity or refusals.
Two cognitively intact residents with significant ROM and mobility limitations did not receive their care-planned restorative nursing programs as ordered. One resident with DM, neuropathy, above-knee amputation, and CKD reported increasing stiffness and weakness and stated that staff no longer brought her for exercises; records showed only sporadic lower extremity and kinetic bike sessions over several months despite physician orders and a care plan for regular AROM and restorative activities. Another resident with RA, polyneuropathy, and prior fractures, who used a power wheelchair, reported not receiving her prescribed exercise program and feeling she was losing strength; her MDS and restorative documentation showed no completed restorative exercises or standing with a walker despite a detailed restorative care plan. Therapy staff and RAs confirmed written restorative recommendations and expectations for 3–6 sessions per week, but reported that two RAs were responsible for about 44 residents, could not see all residents daily, prioritized those more willing or independent, and were unsure when these two residents last received restorative exercises, while the DON acknowledged awareness of staffing difficulties and confirmed the minimal restorative services actually provided.
Staff failed to maintain dignity, hygiene, and privacy for multiple dependent residents. A resident with severe cognitive impairment and depression was left in bed in nightclothes with dried food and juice on her body and linens, and was observed with a dried substance on her nose that was not cleaned over time, despite her reliance on staff for all personal care. Another cognitively impaired resident, dependent on staff for hygiene and dressing, was repeatedly observed wearing a heavily soiled shirt, with food in his beard and thick residue on his fingers, and continued to spill coffee on himself in the dining room without staff assistance or interventions; there was no documentation that he refused care. A third cognitively impaired resident with severe mental illness and risk for abuse and neglect was provided incontinence care while standing at the sink in a shared room without adequate use of the privacy curtain or window blinds, allowing his roommate and potentially others to see him during intimate care, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment, dementia, metabolic encephalopathy, a history of stage II pressure ulcers, and a urinary catheter was left in a dining room for about ten hours without receiving care as outlined in the care plan. The resident’s plan required repositioning every two hours, substantial assistance with toileting hygiene every two to three hours, monitoring of urine output each shift, and extensive assistance with transfers and wheelchair mobility. On the day of the incident, the resident was brought to the dining room in the morning and not returned to his room until evening, and the assigned CNA and LPN did not provide the scheduled care during this time. The facility’s investigation determined that this failure to follow the care plan and provide necessary care for an extended period constituted neglect.
A resident with a history of making allegations of rough care and a care plan requiring all care to be provided by two caregivers was assisted by a single CNA, contrary to the documented "cares in pairs" intervention. The care plan identified manipulative behavior and alleged mistreatment, and specified that two caregivers should be present to address the resident’s needs and observe the entire care session. On one occasion, the CNA entered the room alone and began providing care, after which the resident reported to an LPN that the CNA had been rough, leading to a deficiency citation for failure to follow the resident’s care plan under F684.
Two residents who required two-person assistance with mechanical lifts were subjected to unsafe transfers when CNAs used improperly sized, mispositioned, or incompatible full-body slings and did not follow manufacturer instructions. In one case, a resident newly admitted with a hospital-provided sling was lowered to the floor during a lift transfer after sliding forward in the sling, resulting in reported rib pain but no fractures on X-ray. In another case, a resident’s wheelchair pad and handle became entangled in a large sling during a lift, causing the wheelchair and resident to be lifted off the floor; the sling remained incorrectly positioned at mid-back when the resident was lifted again and moved to bed. Multiple CNAs and nurses reported no recent facility-specific training or competencies on mechanical or sit-to-stand lifts, selected sling sizes by guessing based on body type or using whatever sling was in the room, and lacked clear, updated care plan or Kardex documentation specifying lift type and sling size for residents who required mechanical lifts.
A resident with moderately impaired cognition, Parkinson’s disease, dementia, high fall risk, and moderate pressure-ulcer risk, who required a sit-to-stand lift and maximal assistance for toileting and hygiene, was taken to a beauty shop bathroom by a CMA and left unattended with the lift attached, the door closed, and no call light activated. The resident was later found by a nurse after an extended, unknown period and had transient redness on the buttocks consistent with prolonged sitting. Documentation lacked a post-incident pain and skin assessment. Staff interviews showed there was no clear, consistent process for how often CNAs should check on residents left on toilets, and an observation revealed a staff member failed to change the beauty shop door sign to indicate occupancy, all occurring under a facility neglect policy that defines neglect as failure to provide necessary goods and services to avoid harm.
Failure to Follow Physician Orders and Notify Providers for Infection Management and Dialysis-Related Care
Penalty
Summary
The deficiency involves failures to follow physician orders in a timely manner and to notify providers of significant clinical information for two residents. For one resident with moderate cognitive impairment, respiratory failure, pneumonia, and an indwelling urinary catheter, the physician ordered a UA/UC after the resident’s son reported increased confusion and requested urine testing. The order for catheter change and urine collection was received and noted, but the catheter change documented on the treatment record as due on one date was not completed until early the next morning. Lab reports show urine samples collected on two different dates and times, with one sample having been collected and then recollected. The resident’s son reported being told that a urine sample had sat in the refrigerator too long and had to be recollected, and that the facility did not start the initially ordered antibiotic while the culture was pending. The lab ultimately reported Enterobacter cloacae complex in high colony counts, and the physician ordered cefuroxime, then later discontinued it and ordered nitrofurantoin based on susceptibility results. The cefuroxime order, faxed on a Friday, was not implemented because it remained on a fax machine in the front reception area over the weekend and was not found until the following Tuesday, at the same time the later order to stop cefuroxime and start nitrofurantoin was found. The cefuroxime order was not noted as reviewed by staff, and the preliminary and final culture reports, including susceptibility results showing the organism was not susceptible to cefuroxime but was susceptible to nitrofurantoin, were not consistently documented as reviewed with clear dates and staff identifiers. Progress notes document ongoing confusion, flank pain, and the resident’s belief that there was urine in her oxygen tubing, as well as the son’s concerns and request for transfer to the emergency room. The DON later documented that her investigation found the 7/11 cefuroxime order had not been started because it was discovered only when the 7/15 order to stop it and start nitrofurantoin was located, and interviews revealed uncertainty about why the UA was recollected and that the incident investigation did not address the delayed UA collection or lack of on-call physician notification for preliminary lab results. For a second resident with intact cognition and diagnoses including ESRD on dialysis, hypotension, hypertension, and heart failure, physician orders directed dialysis three times weekly, Midodrine three times daily for hypotension with a parameter to hold if SBP was 120 or greater, and daily Metoprolol Succinate ER for hypertension without hold parameters. The March MAR shows the resident did not receive Midodrine on the mornings of dialysis days and received Metoprolol only once on a dialysis day during a specified period, with no documentation that the physician was notified of these omissions. Dialysis records show pre-dialysis BPs in the low-normal range, and the MAR documents very low BPs on one evening and the following morning, with no documentation that the provider was notified of these low readings. The TAR required monitoring for post-dialysis complications, including hypotension symptoms, twice daily on dialysis days, but only one day in the month reflected documented symptoms. Interviews with nursing staff and the DON confirmed expectations that physician orders be processed within the shift, that abnormal labs and out-of-parameter vitals be reported, and that Midodrine be given before dialysis when within parameters, but also revealed uncertainty about processing timelines, lack of a facility policy on vital sign parameters, and that the physician was not notified about the inconsistent administration of Midodrine and low blood pressures. Facility policies required following all physician orders and notifying the physician when orders were not followed or when there was a significant change in status, but these were not adhered to in these cases.
Failure to Implement Individualized Pressure Ulcer Prevention and Treatment for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and individualize pressure ulcer prevention and care for two residents at high risk for skin breakdown, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment, diabetes, depression, and high Braden risk was dependent on staff for hygiene, repositioning, and transfers. On admission, she had no skin breakdown but was identified as at risk. Her care plan initially addressed potential skin impairment but did not include individualized repositioning or pressure-relief interventions beyond standard admission practices. Staff and leadership later acknowledged that the pressure ulcer prevention measures in place before her ulcer developed were standard for all admissions and not tailored to her specific risk factors. For this resident, documentation showed blanchable redness to the buttocks on a skin assessment, followed by identification of a facility-acquired abrasion to the left buttock and coccyx and additional undescribed areas on the backs of both thighs. The next day, the abrasion on the left buttock was documented as a stage II pressure ulcer, which later increased in size. Observations on multiple days showed the resident lying in bed on her back with the head of the bed elevated and her body bent at the chest, with staff acknowledging that this positioning increased the risk of shearing when she slid down in bed. Interviews revealed that she could not turn herself in bed and required staff assistance for repositioning, yet there was no documentation that she was turned every two hours, and the DON could not find evidence that she refused repositioning or barrier cream. CNAs and a restorative aide reported not knowing what pressure prevention interventions were in place for her, and one CNA left her in bed all day because the resident did not respond when asked if she needed anything, despite the resident’s inability to use the call light or reposition herself. The second resident had multiple serious medical conditions, including spinal stenosis, chronic kidney disease, atherosclerotic heart disease, dysphagia, and protein-calorie malnutrition, and was assessed as high risk for pressure ulcers on the Braden scale. He had a history of multiple pressure ulcers and other wounds that had previously healed, but subsequent skin evaluations documented recurrent redness and pressure areas, including a right gluteal fold pressure ulcer and coccyx involvement. Progress notes identified a bleeding open area under the right buttock, reclassification of a right gluteal fold lesion from MASD to a pressure ulcer, and later documentation of a large coccyx pressure area, a left lateral heel DTI, and a left lateral lower leg stage II pressure blister. His care plan listed multiple active pressure injuries and interventions such as an air mattress, pressure-redistributing cushions, wound treatments, and weekly wound monitoring. Despite these identified wounds and orders, the record showed that ordered wound care treatments were not documented as completed on at least one ordered date, and the DON agreed that if treatments were not signed as completed, they were not done, and that wounds would worsen if treatments were missed. Interviews with nursing leadership and the wound nurse indicated that the resident was not on a formal repositioning schedule, even though standard practice was to reposition residents every two hours, and that his heels were offloaded and repositioned only “as needed.” Staff reported that he often refused to get up in his wheelchair and refused heel lift boots, but refusals and effective approaches were not consistently documented. A PA-C stated she would expect preventative measures such as an air mattress to prevent recurrence of pressure ulcers, and the DON and RN unit manager confirmed that an air mattress was ordered only after multiple pressure injuries were documented. The facility’s own Skin and Pressure Injury Prevention Program policy required offering repositioning at least every two hours for bedfast residents, considering off-loading when the head of bed was elevated, and using special mattresses as indicated, but the documented care and staff interviews showed gaps between these policy requirements and the actual implementation of pressure ulcer prevention and treatment for this resident. Overall, for both residents, surveyors identified failures to consistently implement and document individualized pressure ulcer prevention measures such as scheduled repositioning, appropriate use of pressure-relieving surfaces, barrier creams, and heel offloading, as well as failures to ensure staff understood and followed care plan interventions. These failures occurred despite both residents being clearly identified as high risk for pressure injury and, in the second case, having a documented history of prior pressure ulcers and multiple active wounds.
Unsafe Transfers and Unsecured Chemicals Leading to Resident Injury and Exposure Risk
Penalty
Summary
The deficiency involves failures to ensure safe transfers in accordance with resident care plans and to secure hazardous chemicals from resident access. One resident with hemiplegia following a stroke and severe cognitive impairment, who was care planned to transfer with one staff using a sit-to-stand lift, was transferred by a CNA without the lift from the toilet to a wheelchair. During this transfer, the resident’s legs gave out, he was lowered to the floor, and his head struck the wall, resulting in a skin tear on his left forearm, a bump on the back of his head, and elevated blood pressure and pulse. A CT scan later revealed a subdural hematoma. The DON reported that the CNA had been educated that same morning on the importance of following resident care plans, and the CNA stated she did not use the stand lift because she believed she could complete the transfer faster without it. A second resident with senile degeneration of the brain and severely impaired cognition was also not consistently transferred according to her assessed needs and care plan. Her care plan initially indicated use of a sit-to-stand lift, but a lift assessment documented that she could not bear at least 50% of her weight on one leg, could not sit upright without physical assistance, and could not follow simple instructions, which meant she did not meet the criteria for a sit-to-stand lift. Despite this, the assessment summary still indicated she was to use a sit-to-stand lift for bed-to-chair transfers, and she was care planned to use a sit-to-stand lift until later revised to a full-body mechanical lift. The resident’s family member reported concerns about transfers, including that staff did not use a gait belt, that she had assisted staff with pivot transfers, and that staff sometimes used a sit-to-stand lift and sometimes pivot transferred the resident with two staff. A CNA/CMA described pivot transferring this resident with the assistance of the family member by placing their arms under the resident’s arms and moving her from bed to a bath chair, during which the resident did not follow directions or move her feet, and the CNA/CMA held the resident up while quickly pulling the bath chair under her. Documentation and communication tools used by staff to determine transfer methods were not consistently accurate or up to date. Staff reported relying on the Kardex and pocket care plans to determine how residents should be transferred, and multiple staff acknowledged that pocket care plans were not always kept current. For the second resident, the pocket care plan at one point indicated she was a pivot transfer with one staff, while her family stated she required at least two staff for a pivot transfer and had previously used a mechanical lift in another facility. Later, the undated pocket care plan for her hallway indicated she was to be transferred with a full-body mechanical lift and sling. The DON and administrator confirmed that the initial lift assessment for this resident showed she was not a candidate for a sit-to-stand lift, yet she was care planned to use one. The deficiency also includes unsecured hazardous chemicals accessible to residents in a bathtub room and in the main dining area. On multiple observations, the blue hallway bathtub room door was open with no staff present, and a pink crate on top of the bathtub contained two spray bottles, one labeled Multi-Surface Peroxide cleaner with warnings that it causes skin irritation and serious eye damage, and another unlabeled bottle two-thirds full of an unknown liquid. Staff, including a CNA and RN, stated the bathtub room doors were supposed to be closed and locked to prevent resident access and exposure to unsecured chemicals, and the DON and regional nurse consultant confirmed the presence of the labeled and unlabeled chemicals and that the unlabeled bottle did not contain water. In the main dining room, an unattended housekeeping cart was observed with residents present and no staff nearby. The cart contained an open bottle of toilet bowl cleaner on an unlocked portion of the cart, and additional chemicals, including Multi-Surface Peroxide cleanser and Micro Kill foaming disinfectant cleaner, were stored in a lockable compartment that was left unlocked, with the keys on top of the cart. The administrator verified that the chemicals were not secured from resident access and that the bathtub room was supposed to be closed, locked, and accessible only by staff, and that chemicals were expected to be stored in their original labeled containers in a secure location.
Failure to Honor Resident Bathing Preferences and Scheduled Bathing Frequency
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor residents’ rights to choose and receive bathing at the frequency specified in their care plans and preferences. Multiple residents who preferred bathing at least twice weekly did not consistently receive baths or showers as scheduled, and staff did not consistently document refusals or reasons for missed baths. For one resident with severely impaired cognition, the care plan dated 3/25/26 indicated a preference for two baths per week, yet electronic records from 1/28/26 through 3/25/26 showed she received a bath on 3/9/26 and 3/16/26, refused on 3/13/26, was marked as “not available” on 3/20/26 without any supporting documentation that she was out of the facility, and had no documentation of being offered or receiving a bath on 3/23/26. A family member reported concerns that this resident had only received one shower since admission and raised these concerns to the administrator. Another resident with moderately impaired cognition had a care plan dated 3/25/26 indicating a preference for two baths per week. The bath schedule showed he was to receive baths or showers twice weekly on specific days, and there was no documentation of refusals. However, bathing records from 1/28/26 through 3/25/26 showed gaps of six and seven days between some baths, including a seven‑day interval before a bath on 2/21/26 and a six‑day interval before a bath on 3/13/26. This resident reported that there were times he did not receive a bath for a week, that he had to repeatedly remind staff to get a bath, and that the days he was bathed were inconsistent, sometimes occurring every other day and other times with a week between baths. A cognitively intact resident with a care plan preference for two baths per week was scheduled for baths on two specific days each week, but bathing documentation showed missed baths on multiple dates with no refusals recorded. As a result, there were intervals of seven and ten days between baths. This resident stated he did not receive the showers he was supposed to and was unsure if he would receive a scheduled shower on the day of interview. Another resident with moderately impaired cognition, whose care plan indicated a preference for two to three showers per week and who was scheduled for showers on Sundays and Thursdays, had multiple missed showers without documented refusals and repeated six‑day gaps between bathing. During observation and interview, this resident had long, jagged fingernails, smelled of urine, and reported that showers were sometimes not provided on scheduled days or were changed, and that staff had told him he would not get a shower because the shower was being repaired. The facility’s own bath schedule listed specific days for each of these residents to receive baths or showers, but documentation and resident interviews showed that these schedules were not consistently followed. The grievance log from November 2025 through March 2026 recorded multiple resident complaints and resident council concerns about not receiving baths or showers as expected, including reports from several residents that they had gone extended periods without bathing and that staff told them they were being skipped because other residents had waited longer or due to staffing issues. During a resident council interview, several residents reiterated that baths were not completed as scheduled and described waiting from eight days up to three weeks between baths, as well as equipment issues such as a broken chair that prevented bathing. Nursing staff, including an RN and a restorative aide, acknowledged receiving complaints that residents were not getting baths as scheduled and stated that residents sometimes went more than a week without a bath, and that missed baths could contribute to odors, dignity concerns, and skin conditions. The DON stated she expected residents to be bathed according to their care plan preferences and that refusals should be documented, but she was aware of prior grievances about missed baths. The facility’s bathing policy stated that residents have the right to choose the timing and frequency of bathing and required documentation of bathing activity or refusals and reapproach after refusals, but the documented patterns and interviews showed that these requirements were not consistently met.
Failure to Provide Planned Restorative Nursing Programs for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide ongoing restorative nursing programs as care planned and ordered for two cognitively intact residents with limited ROM and mobility. One resident, with Type 2 DM with diabetic neuropathy, an above-knee amputation, adjustment disorder with depressed mood, and stage 4 CKD requiring dialysis three times weekly, reported frustration that the fingers on her right hand were stiff and that she could no longer make a fist. She stated she felt weaker and believed she was not receiving the exercises she needed, explaining that she previously had exercises but no longer was brought for them. She reported that when she complained to therapy about not getting her exercises, she was told that restorative nursing aides were now responsible for providing them. Record review for this resident showed a physician note directing staff to encourage participation in restorative activities and a physician’s order for staff to encourage restorative activity three times weekly with a progress note to be completed on day shift when done. Her care plan included participation in restorative therapy with a goal to maintain current functional ability and interventions of AROM per therapy and nursing recommendations. Her MDS documented functional limitations in ROM in one upper and one lower extremity and indicated she received only two days of AROM restorative nursing programs in the seven-day look-back period. Restorative documentation from mid-December through late March showed that for lower extremity exercises she was documented as not available on multiple days, refused on several days, and not applicable on others, with only two days of restorative lower extremity exercises provided. For kinetic bike exercises over a three‑month period, she was documented as not available or refusing on multiple days, with several days marked not applicable, and only four days of kinetic bike restorative exercises completed. A second resident, who used a power wheelchair, had limited use of upper and lower extremities, and diagnoses including rheumatoid arthritis, polyneuropathy, and fractures of the right lower leg and foot, reported via an iPad translation device that she had participated in PT on admission and was discharged to a restorative program. She stated she was upset that she had not been receiving her exercise program, had complained to the DOR, and felt she was losing strength and her ability to stand and transfer. Her BIMS score indicated she was cognitively intact. Her MDS showed functional limitation in ROM in one lower extremity and no restorative nursing exercise programs received. Her care plan called for participation in a restorative therapy program to maintain functional abilities, with interventions including AROM, sitting exercises with a 3‑lb green TheraBand, trunk exercises x15 reps, and transfers involving standing with a walker up to 10 minutes. Restorative documentation from late January through late March showed multiple refusals and days marked not applicable, with no documentation that she received lower extremity exercises or stood with her walker for ten minutes during that period. Interviews with therapy staff and restorative aides revealed that therapy had provided written restorative recommendations on transfer forms, and the DON was responsible for setting up the programs. The therapy team expected two restorative aides to complete the recommended exercise programs, including upper and lower extremity exercises three to six times per week for the first resident (arm bike, recumbent kinetic bike, 5‑lb weights, green bands) and a lower extremity program three to six times per week for the second resident (standing with walker for ten minutes, 3‑lb weights, green bands). One restorative aide reported that she and the other aide were responsible for restorative exercises for about 44 residents, each scheduled for 15 minutes daily, and that it was impossible to see all residents when only one aide was working. She stated some residents were prioritized because they were ready, independent in getting to the exercise room, and enjoyed exercising, while others known to refuse were deprioritized when staff were busy. She acknowledged not having completed restorative exercises with the first resident recently and not having done restorative exercises with the second resident in over a month. The other restorative aide confirmed workload challenges, restrictions on being alone with the first resident, difficulty coordinating use of the main therapy room and equipment, and uncertainty about when either resident last received restorative exercises. The DON and regional nurse consultant confirmed that the facility’s policy defined restorative nursing as interventions to promote optimal functioning, that residents with written programs were expected to receive at least 15 minutes per day, and that the first resident had received only seven days of restorative exercises since mid‑December while the second resident appeared to have received none since late January, and they were unaware of the residents’ concerns.
Failure to Maintain Resident Dignity, Hygiene, and Privacy During Personal Care
Penalty
Summary
The deficiency involves failures to maintain resident dignity, hygiene, and privacy for multiple residents who were dependent on staff for personal care. One resident with severely impaired cognition, depression, and senile degeneration of the brain was dependent on staff for dressing, personal hygiene, and transfers with a full body lift. Her care plan required staff to use yes/no questions and clear explanations due to her communication difficulties. Her family reported concerns that she was not being changed regularly, was left in bed in her nightgown until mid-afternoon, and was not assisted out of bed to the dining room for meals. The family also reported finding dried juice on the resident’s stomach and bed sheets on consecutive days, indicating the linens had not been changed, and later finding the resident in bed around mid-afternoon in pajamas with food on her face and clothing. During the survey, the resident was observed in the afternoon with a dried green substance on her nose that remained there over an extended period, despite her dependence on staff for hygiene. Another resident with severely impaired cognition, unclear speech at times, and dependence on staff for personal and oral hygiene and dressing was repeatedly observed with soiled clothing and unclean hands and face. He was first seen lying in bed wearing a white shirt with multiple brown discolorations on the chest and arms. Later the same day, he was observed in the dining room wearing the same soiled shirt and spilling coffee repeatedly onto his clothing protector and shirt without staff offering assistance or interventions to prevent further spillage. That afternoon, he was again observed in bed wearing the same dirty shirt with food in his beard and stated he would have liked staff to change his shirt and that he had trouble with spilling food and drinks and wanted more assistance with eating and drinking. On another day, he was observed twice in the hallway with food in his beard and a thick orange substance on his fingers around his fingernails, as well as food on his shirt, with no indication in the record that he had refused clothing changes or hand and face washing. A third resident with severely impaired cognition, depression, anxiety, and a care plan noting severe mental illness with risk for abuse and neglect did not receive adequate privacy during incontinence care. Two CNAs assisted this resident in his shared room by placing a gait belt, helping him stand at the sink, lowering his pants, removing his incontinence brief, cleaning his private areas, and applying a new brief while his roommate was in bed. The privacy curtain was not pulled far enough to prevent the roommate from seeing the resident, and the window blinds were open, leaving him exposed during personal care. Staff interviews confirmed that residents’ clothing should be changed when soiled, faces and hands washed after meals or when soiled, refusals documented, and privacy ensured by closing doors, blinds, and curtains during personal care. The observations and interviews showed that these expectations and the facility’s dignity and privacy policy were not followed for these residents.
Resident Left in Dining Room for Extended Period Without Required Care
Penalty
Summary
The deficiency involves a resident with severe cognitive impairment who was left in the dining room for approximately ten hours without receiving care as outlined in his care plan. According to the SD DOH Facility Reported Incident, the resident was brought to the dining room at around 8:30 a.m. and was not taken back to his room until 6:31 p.m. that day. During this period, the resident did not receive identified interventions to meet his care needs from the CNA and LPN assigned to him. The facility’s investigation determined that the resident was neglected because his care plan was not followed and necessary care was not provided for an extended period. The resident’s medical record showed he had a BIMS score of 1, indicating severely impaired cognition, and diagnoses of metabolic encephalopathy and dementia. His care plan documented that he was at risk for skin impairment due to a history of stage II pressure ulcers, required repositioning every two hours and as needed, had a urinary catheter with urine output to be documented each shift, and required substantial assistance with toileting hygiene every two to three hours, transferring, and wheelchair mobility. He was also identified as being at risk for falls and was to be treated with respect and dignity and to reside free of mistreatment. Despite these documented needs, the resident remained in the dining room for about ten hours without the planned care being provided. The FRI report noted that the resident had a urinary catheter, could move and readjust himself in his wheelchair, was forgetful, and needed staff assistance with using the bathroom. Although his skin assessment after the incident did not show skin breakdown related to the event and he was not incontinent of bowels, the facility’s investigation concluded that the failure of the assigned CNA to follow the care plan and provide care during the prolonged period in the dining room constituted neglect. Interviews with the DON confirmed that the facility’s investigation found the resident had been neglected by staff on that day because his care needs, as specified in his care plan, were not met for approximately ten hours.
Failure to Follow Care Plan Requiring Two Caregivers During Resident Care
Penalty
Summary
Non-compliance at F684 occurred when a resident who was care planned to receive all care from two caregivers at all times was assisted by a single CNA. The resident had a documented history of making allegations of staff being rough and was identified in the care plan as requiring "cares in pairs" with two caregivers present to address her needs and observe the entire care session. Despite this, the CNA entered the resident’s room alone and began providing care without a second staff member present, contrary to the resident’s care plan and the facility’s expectations. The resident’s care plan, initiated on 10/28/22, identified manipulative behavior and alleged mistreatment as focus areas, noting that the resident might voice allegations of mistreatment or exploitation by caregivers, related to feelings of loss of independence, and might use abusive language. Interventions included assuring the resident she was safe and secure, providing two caregivers to address her needs and observe the entire session, having supervisory personnel observe care delivery as much as possible, and offering staff of certain racial backgrounds when able, based on the resident’s stated preferences and history of accusations. On the date of the incident, the resident reported to an LPN that the CNA had been rough with her during care that was provided without a second caregiver present. Staff interviews confirmed that the resident was known to make accusations, tell inconsistent stories, and sometimes scream even before being touched, and that she was to always receive care with two staff present because of these behaviors and prior allegations. On the day of the incident, staff on duty reported hearing the resident screaming after the CNA entered the room and began helping her, then left to get a second person to assist. The CNA acknowledged going into the room alone and assisting the resident with care, thereby not following the resident’s care plan requirement for two caregivers to be present during care, which led to the cited deficiency under F684.
Improper Mechanical Lift Use and Inadequate Sling Selection for Dependent Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of total body mechanical lifts and appropriate slings for residents requiring two-person assistance for transfers. Contracted travel CNAs and facility CNAs used incompatible or improperly sized and positioned slings, and staff lacked clear, accessible information on which sling size and type to use for specific residents. Surveyors identified that staff often selected sling sizes based on visual estimation of body size or by using whatever sling was present in the room, rather than following resident-specific guidance. Care plans and Kardexes for multiple residents who required mechanical lifts did not specify the type of lift (full body or sit-to-stand) or the correct sling size, leaving staff without written direction. One incident involved a resident who had been admitted earlier that day with a full body lift sling brought from the hospital. During a transfer from wheelchair to bed using a full body lift, two CNAs attached the sling provided by the family and began the transfer. As one CNA attached the lower body sling straps to the lift hooks, the resident moved and slid forward in the sling. The CNAs readjusted the resident and completed attaching the sling, but the resident continued to move and slid toward the edge of the wheelchair seat, causing the sling to tilt downward. Unable to safely complete the transfer, the CNAs lowered the resident to the floor using the upper portion of the sling while the lower portion remained attached to the lift. The resident’s buttocks contacted the floor first, she was then assisted to a lying position, and she reported rib pain; a subsequent chest X-ray showed no breaks or fractures. This event was identified as the start of Immediate Jeopardy at F689. Another observed incident involved a different resident being transferred from a wheelchair to a bed using a full body lift and a burgundy (large) sling. Two contracted travel CNAs placed the sling behind the resident, pulled the lower straps under her thighs, and interlaced the straps. As they began lifting, the resident’s wheelchair pad and the left handle of the wheelchair became caught in the sling, causing the wheelchair to lift off the floor with the resident still seated. While the resident and wheelchair were suspended, one CNA pulled on the wheelchair pad to free it, and the CNAs switched tasks while the resident remained in the air. After lowering the resident and wheelchair back to the floor and freeing the wheelchair handle, they did not reposition the sling, which was noted to be placed too high, with the bottom of the sling at the resident’s mid-back instead of under her buttocks. They then lifted the resident again and transferred her to the bed, with one CNA stating during the lift that the setup was “all wrong.” Interviews with multiple CNAs and nursing staff revealed that many had not received recent or any facility-specific training or competencies on safe use of mechanical lifts and sit-to-stand lifts. Several CNAs reported choosing sling sizes based on the resident’s body type or guessing, and one CNA stated she relied on training from previous employers. Staff were generally unaware of which sling to use for specific residents and could not readily locate up-to-date written resources; binders that were supposed to contain lift and sling information were missing or outdated. A paper list of sling sizes found in a communication binder was acknowledged by an RN as not updated. Another RN stated she did not know residents’ sling sizes and would ask a CNA for guidance. Record review confirmed that not all direct care staff, including CNAs involved in the incidents, had completed required competencies on total body lifts or sit-to-stand lifts after the reported incident, despite having worked shifts since that time. Further review of resident records showed that for several residents who used mechanical lifts, care plans and Kardexes lacked documentation of sling size and, in some cases, did not even specify the type of lift to be used. For example, one resident’s care plan and Kardex indicated a need for two-person assistance with transfers but did not identify any transfer equipment. Surveyors also compared an updated list of transfer equipment to slings stored in residents’ rooms and found discrepancies between listed sling sizes and those actually present or documented in the Kardex for certain residents. The facility’s own sling sizing chart and manufacturer’s instructions for the EZ Way Smart Lift outlined proper sling positioning and sizing parameters, including that the base of the sling should be positioned two inches below the tailbone and the top parallel with the shoulder line, but observed practice and staff statements demonstrated that these guidelines were not consistently followed.
Resident Left Unattended on Toilet Resulting in Potential Neglect
Penalty
Summary
The deficiency involves a resident being left unattended on a toilet in the beauty shop bathroom for an extended period, despite requiring staff assistance and supervision. The resident was later found by the charge nurse sitting on the toilet with the sit-to-stand lift still attached, the bathroom door closed, and the call light not activated. Prior to this, a CNA had noticed the resident’s room call light on, but the resident was not in his room; the CNA turned off the call light and proceeded to answer other call lights without locating the resident. The facility’s investigation identified that a certified medication aide (CMA) had taken the resident to the beauty shop bathroom earlier in the afternoon but did not inform other staff or acknowledge doing so, even though witnesses reported seeing the CMA escort the resident to that bathroom. The resident’s medical record showed moderately impaired cognition with a BIMS score of 8, diagnoses including Parkinson’s disease, unspecified dementia, hallucinations, and sensorineural hearing loss, and a high fall risk with a Morse fall scale score of 75. The care plan documented the need for a sit-to-stand lift for transfers, maximal/substantial assistance for toileting, and dependence on staff for toileting hygiene, as well as a focus on risk for pressure ulcer development related to immobility and incontinence. A Braden scale score of 13 indicated moderate risk for pressure ulcers. After being left on the toilet for an unknown but extended time, the resident was assessed by the charge nurse and found to have slight redness on the buttocks consistent with prolonged sitting on the toilet seat; the redness resolved before the end of the shift. There was no documented pain assessment or skin assessment in the medical record following this incident. Staff interviews revealed inconsistent practices and lack of clear guidance regarding monitoring residents left on toilets. One CNA reported checking assigned residents every two hours and returning to the bathroom within five to ten minutes if a resident did not use the call light, noting that longer periods on the toilet could cause redness from pressure. Another CNA stated that some resident bathrooms were too small for lift equipment, so residents were taken to the beauty shop bathroom, but there was no specific process or policy on when staff should return to assist residents off the toilet; she relied on remembering to go back. During observation, a staff member transferred a resident into the beauty shop and closed the door without changing the door sign from “Vacant” to “Occupied.” The facility’s neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and outlined procedures for investigation and protection of residents, but there was no documentation that audits were conducted to ensure staff understood and implemented resident safety interventions related to this incident.
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