Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palisade Healthcare Center during CMS and state inspections, most recent first.
Multiple residents with incontinence, impaired mobility, and high pressure-injury risk were not changed or repositioned as ordered or expected, resulting in prolonged periods in wet briefs, extended time in the same position, and failure to use pressure-relieving measures such as heel elevation. One resident with a history of coccyx pressure injury had a previously healed area reopened when a CNA cleaned the area roughly with a dry wipe and spray, causing a stage II ulcer, while another resident developed bright red, superficially open perineal and inner thigh areas after reporting that his brief had not been changed for a long time and that call lights often went unanswered for hours. Additional residents reported or were observed experiencing delayed toileting assistance, call lights out of reach, rough or non-communicative care, and refusal or failure by CNAs to provide requested hygiene or clothing changes, demonstrating neglect of basic care needs and, in one instance, abusive rough perineal care.
Surveyors found that call lights, used by residents to request staff assistance, were repeatedly left out of reach for multiple residents in bed, including one who reported never having access to her call light and another who was calling out for help to use the bathroom while her call light lay at the foot of the bed despite high fall-risk signage. Observations showed call lights hung over headboards, clipped to wall cords, lying near the floor, or placed on tables and recliners away from residents, while CNAs, a CMA, an RN, an LPN, and the administrator all acknowledged that call lights were expected to be within residents’ reach but were not in these instances.
A resident with urinary retention, bladder disorder, and a suprapubic catheter was ordered to have twice-daily catheter flushes with normal saline and 5% vinegar. An LPN reported reusing a labeled graduated cylinder for the irrigation solution while only changing the syringe, despite facility policy requiring sterile equipment and the availability of sterile catheter kits. The DON acknowledged the container should be changed each time and that the resident had experienced UTIs, while a nurse manager training as the infection preventionist was unaware non-sterile cylinders were being used. The administrator stated the LPN had been educated on catheter kits and that nurses should understand sterile field requirements.
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.
Neglect of Incontinence Care, Repositioning, and Rough Perineal Care Leading to Skin Breakdown
Penalty
Summary
The deficiency involves multiple failures to protect residents from neglect and abuse, primarily related to untimely incontinence care, inadequate repositioning, and rough handling during perineal care. Several residents with high risk for pressure injuries and impaired mobility were not changed or repositioned according to their care plans or leadership expectations. One cognitively intact resident with a high Braden risk score and a history of pressure ulcers was documented and confirmed by staff to have gone approximately four to four and a half hours without being changed or repositioned, despite care plan expectations for frequent repositioning and incontinence care with barrier cream. Observations showed this resident lying on her back for extended periods, with a wet brief and lift sheet, slightly red groin and buttocks, and heels not propped on pillows as ordered. CNA staff acknowledged that the resident should have been changed and repositioned every two hours and that this was not done or documented as required. Another resident with moderately impaired cognition, a Braden score indicating risk for pressure ulcers, and an existing stage IV coccyx pressure ulcer was not repositioned or changed for several hours, contrary to care plan directions for routine side-to-side repositioning, heel elevation, frequent toileting, and barrier cream use. Observations showed this resident remaining on the same side or on her back for extended periods between documented care episodes. A nurse later stated that this resident was not to be positioned on her back due to the stage IV coccyx ulcer. The resident also reported that a CNA had been rough and non-communicative during night care and had refused to change her shirt when requested, and surveyors observed her wearing the same shirt from the previous day, with heel boots sliding off and heels resting on the bed while she complained of heel pain. A third resident with severe cognitive impairment, high pressure-ulcer risk, incontinence, and a history of coccyx pressure injury reported feeling that her brief was "flooded" and her bottom was sore, and that some staff were rough during care. Her care plan required frequent toileting, barrier cream, use of a lift sheet, and pressure-relieving devices. A hospice RN expected repositioning and incontinence care every two hours. However, CNA documentation and interviews showed that she was not consistently changed or repositioned every two hours, and her Kardex did not specify the required frequency. In addition, an incident occurred in which a CNA cleaned her coccyx area roughly with a dry wipe and cleansing spray, reopening a previously healed fragile area and resulting in a stage II coccyx ulcer; another CNA had to physically intervene to stop the rough cleaning. Further neglect was identified for a resident with quadriplegia, urinary incontinence, high pressure-injury risk, and an air mattress and heel boots ordered. This resident reported that his call light was sometimes unanswered for two to four hours and that his brief had not been changed for a long period on at least one occasion, causing him to sit in urine long enough to develop skin irritation and open sores in the perineal area. Subsequent wound care observations confirmed bright red perineal, inner thigh, and rectal skin with superficial open areas, and the resident stated the sores had been present for a few weeks. The nurse stated CNAs were supposed to check him every two hours, and his care plan required routine turning, ensuring he was clean and dry, and use of barrier cream. Another resident with moderately impaired cognition, stroke-related deficits, and a care plan requiring one staff for bed mobility and personal hygiene, use of a bedpan, perineal cleansing after each incontinent episode, and a call light within reach was observed repeatedly calling out for help. A CNA entered and exited the room, stating the resident wanted to get up or needed the bathroom, but left to find help without providing immediate assistance. When another CNA responded, the resident appeared restless, had a wet brief, and stated she needed to use the bathroom and that no one would help her. Her call light was found at the foot of the bed despite posted signs directing that it be attached to the bed due to her high fall risk. The report also documents resident complaints and staff observations related to disrespectful and neglectful behavior by certain CNAs. One resident reported that a night-shift CNA refused to provide a blanket, was rude when asked for repositioning, and remained on the phone speaking another language during personal care, causing the resident to feel afraid of the CNA and unsure when she might lose her temper. Another resident reported that her incontinence product was not changed overnight and that she did not have access to her call light to request assistance. A CNA reported that a staff member had been sleeping while on duty. Additionally, a resident anonymously reported not being changed at night when requested, and another CNA stated that after one particular CNA worked, residents in that CNA’s care did not appear to have received appropriate care. These events collectively demonstrate failures to provide timely incontinence care, repositioning, and respectful, gentle personal care, resulting in neglect and, in one case, abusive rough perineal care that caused skin breakdown.
Failure to Keep Resident Call Lights Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights, a communication tool for requesting staff assistance, were kept within reach for all 10 sampled residents. Multiple observations showed call lights placed out of residents’ reach in various ways: hung over a headboard, clipped to the wall cord, lying near the floor, placed on bedside or overbed tables pushed away from the bed, or clipped to a recliner instead of near the resident in bed. One resident was observed slid down in bed and stated she did not know where her call light was and never had access to it. Another resident was in bed with the call light clipped to its own cord at the wall, and others were asleep or lying in bed with call lights positioned on tables or furniture not accessible from their positions. Interviews with staff confirmed awareness that call lights were expected to be within residents’ reach and that the observed placements were not appropriate. A resident who was calling out for help reported that no one would answer her call and that she needed to go to the bathroom; her call light was found at the foot of her bed despite signage indicating she was a high fall risk and that the call light should be attached to her at all times. CNAs, a CMA, an RN, an LPN, and the administrator each acknowledged that residents’ call lights were not within reach in the observed situations and stated that residents were supposed to have call lights accessible at all times, but the observations showed this was not consistently implemented.
Improper Non-Sterile Technique Used for Suprapubic Catheter Irrigation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s suprapubic catheter was irrigated using sterile technique and sterile equipment as required by the infection prevention and control program. Observation and interview with an LPN showed that the resident’s suprapubic catheter was flushed twice daily using a reused graduated cylinder that had been labeled "sterile only for vinegar and water, not to empty urine from the catheter," while only the syringe was changed each time. The LPN stated she had been trained to reuse the cylinder but could not recall who trained her. Review of the facility’s undated indwelling catheter irrigation policy indicated that prescribed irrigation solutions were to be used with a sterile basin and that commercially packaged kits containing sterile irrigation solutions, a graduated receptacle, and a catheter-tip syringe may be available. Further interviews revealed that the DON, who had recently started at the facility, understood that the container used for catheter irrigation should be changed every time and acknowledged that the resident had experienced urinary tract infections. A nurse manager training for the infection preventionist role reported she was not aware that non-sterile graduated cylinders were being used for the resident’s catheter flushes and confirmed that sterile urinary catheter kits were available and should have been used. Review of the resident’s EMR showed a physician’s order to flush the catheter with specific amounts of normal saline and 5% vinegar twice daily and as needed for a bladder disorder. The resident’s diagnoses included urinary retention, bladder disorder, overactive bladder, proteinuria, and bladder-neck obstruction, and her medications included cranberry capsules and methenamine hippurate for UTI prevention. The administrator stated that the LPN had been educated regarding the use of urine catheter kits and that nurses should know what a sterile field is.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Garretson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Home - Brandon | 9.3 mi | ★★★★★ | 15 | 0 |
| Dells Nursing And Rehab Center Inc | 13.4 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Mary Jane Brown | 14.3 mi | ★★★★★ | 8 | 0 |
| Mn Veterans Home - Luverne | 14.5 mi | ★★★★★ | 5 | 0 |
| Tuff Memorial Home | 15 mi | ★★★★★ | 9 | 0 |
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