Riverview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Flandreau, South Dakota.
- Location
- 611 East 2nd Ave, Flandreau, South Dakota 57028
- CMS Provider Number
- 435086
- Inspections on file
- 24
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Riverview Healthcare Center during CMS and state inspections, most recent first.
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.
The facility failed to timely submit initial and final FRI reports to the SD DOH for multiple residents who experienced alleged abuse, falls with injury, seizures, head lacerations, and fractures. In several cases, initial reports were submitted many hours or days after serious events, exceeding the required 2‑hour or 24‑hour timeframes, and in numerous instances no final investigation report was ever submitted within the required 5 working days, despite state complaint records and rejections requesting completion. The administrator and DON, who were responsible for reporting and aware of the regulatory timeframes, acknowledged ongoing issues with incident reporting, while the facility’s own abuse reporting policy required immediate reporting of suspected abuse and timely submission of investigation results.
Two residents with significant symptoms did not receive timely completion of ordered diagnostic tests. For one resident with cirrhosis and acute kidney failure who reported painful urination, fever, and urinary urgency, a physician ordered a same‑day UA, but facility staff did not collect the sample as ordered; the resident was later evaluated at a clinic, found to have urinary retention, had a Foley catheter placed, and was treated for suspected UTI. For another resident with intracerebral hemorrhage who had dark black stools and strong‑smelling urine, the physician ordered CBC, CMP, and UA on the same day staff reported these symptoms, but the order was not acknowledged for several days, the CBC result was not available, the CMP had to be recollected, and the UA was delayed and ultimately not obtained after the physician later indicated it was unnecessary without additional symptoms. Staff and the DON acknowledged that physician orders were expected to be processed immediately and that these labs and UA should have been collected on the day the orders were received.
A cognitively intact resident reported that a CNA verbally and physically abused him during evening care, stating he was slapped, pushed onto the bed, and choked. The resident disclosed the alleged abuse to a CNA during a bath, who then informed the SSD, and the concern was brought to the IDT, but the administrator did not promptly follow up that same day. The resident repeated the allegation to an LPN/CC and later to a counselor, while assessments showed no visible injuries. Despite a written abuse policy requiring that all abuse allegations be reported to the state survey agency within 2 hours, the facility did not ensure that this allegation was reported within the required timeframe, resulting in a reporting deficiency.
A resident with significant medical needs and high risk for pressure ulcers developed untreated blisters that progressed to a stage 2 pressure ulcer after staff failed to implement wound care orders, document assessments, or communicate with the wound nurse and primary care provider, resulting in a lack of timely intervention.
A CNA did not secure a safety belt on a whirlpool bath chair while bathing a resident who was totally dependent on staff for transfers and mobility, resulting in the resident sliding out of the chair and falling to the floor. The resident had multiple complex medical conditions and required two-person assistance, but the use of the safety belt was not standard practice at the time. Staff interviews and observations confirmed that the safety belt was available but not routinely used prior to the incident.
Staff failed to protect residents from abuse and neglect, including a CNA responding rudely and aggressively to a resident's pain medication request, a CMA refusing to assist a resident with medication leading to emotional distress, and another CNA escalating a situation with a cognitively impaired resident by acting aggressively and physically taking food from the resident.
A resident with cancer, acute kidney failure, and anxiety experienced worsening abdominal pain and swelling, repeatedly reporting inadequate pain control and requesting to see a specialist. Despite frequent administration of PRN oxycodone, acetaminophen, and lorazepam, staff did not document provider consultation or schedule the required follow-up after an emergency department visit, resulting in ineffective pain management and lack of timely medical intervention.
Two residents did not receive critical physician-ordered medications—one missed multiple doses of anti-seizure medication, resulting in increased seizure activity and ED transfer, while another missed a week of blood thinner due to a lab schedule change and lack of pharmacy notification. Staff interviews revealed inconsistent medication reordering practices, and the facility's policy to reorder with a three-day supply remaining was not consistently followed.
Two residents with cognitive impairment and mobility needs were able to leave the facility without staff knowledge due to failures in supervision, improper use of WanderGuard devices, and lack of enforcement of sign-out procedures. One resident exited through an unalarmed patio door and walked to a bar, while another left through the main entrance when the WanderGuard was incorrectly placed, preventing the alarm from sounding. Staff did not consistently follow or enforce elopement prevention policies, leading to both residents being outside the facility unsupervised.
A facility failed to provide quality care by improperly delegating wound care from an RN to a CNA, leading to inadequate treatment for a resident. Additionally, two residents experienced poor hospice care coordination, resulting in unassessed pressure ulcers and unmanaged pain. The DON was unaware of these issues, highlighting a lack of communication and adherence to care protocols.
The facility failed to prevent and manage pressure ulcers for three high-risk residents. A resident developed stage two pressure ulcers on both heels and an abrasion on the coccyx due to inadequate repositioning. Another resident on hospice care developed a Kennedy ulcer and a thigh injury, with insufficient documentation and communication with the primary care physician. A third resident, severely cognitively impaired, developed stage two pressure ulcers on the coccyx and buttocks due to infrequent repositioning. The DON acknowledged these were preventable and highlighted concerns about staff training.
A hospice resident experienced unmanaged pain during repositioning, with staff documenting zero pain despite visible discomfort. The resident's care plan and physician's orders for pain management were not effectively followed, leading to inadequate pain control.
The facility failed to maintain food safety standards, with unsanitary kitchen conditions, improper food storage, and inadequate hand hygiene during meal service. Observations revealed mold in the cooler, expired food, and incomplete temperature monitoring. Staff did not follow glove use protocols, contributing to the deficiencies.
The facility failed to maintain a homelike environment, with significant damages observed in various areas, including a shared bathroom with exposed chicken-wire ceiling, a rusted emergency exit door frame, and missing flooring in the therapy gym. Staff were aware of some issues but faced delays in addressing them due to contractor scheduling difficulties.
A long-term care facility was found deficient in infection control practices, with an RN and CNAs failing to follow proper hand hygiene and wound care protocols. The RN did not use barriers under wound care supplies and failed to perform hand hygiene between glove changes. CNAs did not sanitize hands before donning PPE and used the same towels for different body parts, risking cross-contamination. The facility's environment, including the whirlpool tub and therapy gym, was not maintained in a cleanable condition, contributing to the deficiencies.
A resident with stage II pressure ulcers on both heels and an abrasion on the coccyx did not have an updated care plan reflecting these conditions. The care plan, last revised months earlier, failed to include the current skin impairments, contrary to the facility's policy. The DON acknowledged the care plan did not meet the resident's current needs.
The facility failed to address deficiencies in pressure ulcer prevention, infection control, and pain management. The medical director was unaware of the lack of a repositioning policy, and the DON acknowledged the need for improvement in infection control and wound care. The QAPI plan did not adequately address these critical areas, and there were environmental issues such as missing ceiling tiles and dirty equipment.
The provider failed to maintain the walk-in cooler and freezer according to industry standards. The cooler door did not seal properly, allowing light and creating a gap, while mold-like growth was observed on various surfaces. The freezer had ice buildup due to improper temperature control, with a condenser panel hanging unsecured and blowing hot air. The dietary manager was aware of these issues.
Two residents with dementia were subjected to physical and verbal abuse by a CNA, including being kicked and having a washcloth placed over the mouth. Despite reports from staff, the facility failed to protect the residents, conduct a thorough investigation, or report the incidents promptly. The DON and ED were aware of the allegations but did not follow the facility's abuse prevention policies.
The provider failed to report and investigate allegations of abuse by a CNA towards two residents. The CNA continued working after the allegations were known, and the initial report to the DOH was delayed. Witnesses indicated a history of abusive behavior by the CNA. The DON and ED were aware of the allegations but did not report them to the required entities.
The provider failed to investigate and report allegations of abuse by a CNA towards two residents with dementia. Despite being aware of the allegations, the provider allowed the CNA to continue working, did not report the incidents promptly, and conducted an inadequate investigation. The DON was unaware of the abuse policy, and the investigation lacked documentation and thoroughness.
The facility's administration failed to ensure resident safety and well-being due to inadequate management by the ED and DON. They did not maintain an effective abuse prohibition program, failing to report and investigate abuse allegations by a CNA towards two residents. Additionally, residents' privacy was compromised by a staff member secretly recording conversations. The DON allowed the implicated CNA to continue working, and the ED was aware of the situation but did not take appropriate action.
A staff member at an LTC facility secretly recorded private conversations of three residents to gather evidence of alleged abuse by a CNA. The recordings were shared with the executive director, who initially denied knowledge of the allegations. The facility's policies prohibit unauthorized recordings, and the staff member was suspended pending investigation for violating HIPAA and company policies.
A resident with dementia and a history of exit-seeking behavior eloped from the facility despite having a functioning Wanderguard. The resident was found a half mile away and returned by staff. The facility failed to conduct a thorough investigation into the incident, and staff misinterpreted the alarm triggered by the resident's exit. The Director of Nursing acknowledged the need for a more comprehensive investigation.
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.
Failure to Timely Report Facility Incidents and Investigation Results to SD DOH
Penalty
Summary
The deficiency involves the facility’s failure to timely submit initial and final Facility Reported Incident (FRI) reports to the South Dakota Department of Health (SD DOH) for multiple residents who experienced reportable events, including alleged abuse, falls with injury, and other serious incidents. For one resident who reported an allegation of abuse on 1/3/26 at 6:00 p.m., the initial report was not submitted until 1/14/26 at 9:45 a.m., approximately 11 days after the event, and the final investigation report was submitted on 1/16/25, outside the required time frames. The SD DOH complaint record stated the facility failed to ensure timely reporting for this resident and that the delay failed to ensure immediate protection and oversight. The administrator acknowledged awareness of the required reporting time frames and responsibility for reporting but could not identify why the reports were not completed on time. The facility also failed to meet reporting requirements for several residents who had falls requiring further medical evaluation. One resident had a fall with a head laceration requiring staples on 12/28/25 at 9:45 p.m.; the initial report was not submitted until 12/29/25 at 8:37 p.m., exceeding the 2‑hour requirement, and the final report was not received until 1/20/26, beyond the 5 working‑day requirement. The SD DOH complaint record stated this failure placed the resident at risk for unaddressed abuse or neglect. The same resident had another fall with a head laceration on 1/4/26 at 2:28 p.m.; while the initial report was timely at 3:29 p.m., no final investigation report was ever submitted. Another resident had a fall on 10/13/25 at 4:18 p.m. with head and pelvic pain; the initial report was timely, but the SD DOH rejected the report twice requesting a final investigation, and no final report was submitted. The DON stated the final investigation report “got stuck in the cracks.” Additional residents experienced falls with injuries or serious symptoms for which the facility did not meet initial or final reporting requirements. One resident had a fall with a head laceration on 11/5/25 at 8:55 p.m.; the initial report was not submitted until 1:41 p.m. the next day, exceeding the 2‑hour requirement, and no final report was submitted despite SD DOH rejections and requests. Another resident had a fall with a seizure on 11/16/25 at 7:30 p.m.; the initial report was not received until 7:11 p.m. the following day, and no final investigation report was submitted. A different resident had a fall with head impact and seizure on 12/5/25 at 9:05 p.m.; the initial report was submitted the next day at 12:12 p.m., and the final report on 12/15/25, both beyond required time frames. One resident sustained a left arm fracture from a fall on 12/17/25 at 5:30 a.m.; the initial report was not received until 12/29/25 at 9:29 p.m., and no final report was submitted, with documentation showing inconsistent event dates. Another resident was involved in alleged potential resident‑to‑resident physical abuse on 11/21/25 at 7:00 a.m.; the initial report met the 24‑hour requirement, but no final investigation report was submitted. Interviews with the administrator and DON confirmed that they were responsible for completing initial and final FRI reports to the SD DOH and that they were aware of the state’s required time frames: allegations, falls of unknown origin, and falls with major injury to be reported within 2 hours, and all other incidents within 24 hours, with final investigation reports due within 5 working days. The administrator acknowledged the facility had issues with reporting FRIs and stated that staff were to call her or the DON at any time to inform them of incidents so they could determine reportability. She reported that all managers had completed education on reportable incidents, and about half of all staff had completed related education by the time of the survey. The facility’s Abuse Reporting and Response policy required immediate reporting of suspected or alleged abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source, and mandated reporting of investigation results to the state survey agency within 5 working days, but the documented events and complaint records showed repeated failures to follow these requirements for nine residents.
Failure to Timely Complete Ordered UA and Lab Work for Two Symptomatic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and complete ordered diagnostic tests for two residents with concerning symptoms. For one resident with alcoholic cirrhosis, ascites, and acute kidney failure, the physician issued an order on 1/12/26 at 2:57 p.m. to collect a urine analysis (UA) sample and bring it to the clinic that day. Nursing documentation later that afternoon recorded the resident’s complaints of painful urination with sharp pain on attempting to void, increased frequency and urgency, a temperature of 101.1°F, pulse of 103, and pain rated 10/10. Despite these symptoms and the explicit same‑day order for a UA, the urine sample was not collected by facility staff on 1/12/26. On the following day, staff documented that the resident’s temperature had increased to 102°F and that the primary care provider requested the resident be seen at the clinic that day and to postpone scheduled GI testing. A late entry note indicated the provider, during in‑house rounds, recommended the resident be seen in the clinic due to fever and nausea. At the clinic, a bladder scan showed 906 cc of retained urine, a Foley catheter was inserted, a urine sample was obtained, IV antibiotics were administered, and oral antibiotics were ordered for a suspected UTI. The DON later confirmed there was no documentation of what information had been sent to the physician before the UA order on 1/12/26 and acknowledged that the UA should have been collected that day as ordered, and that not doing so may have caused a delay in treatment. LPN/CC F also stated the UA should have been collected on 1/12/26. The second resident had a diagnosis of intracerebral hemorrhage and a BIMS score indicating moderately intact cognition. Staff faxed the physician reporting dark black stools for two days and strong‑smelling urine. The physician responded with an order for CBC, CMP, and UA to be done that day, noting the resident was on iron, which could cause dark stools versus GI bleed. The order, faxed on 1/9/26, was not acknowledged in the record until 1/13/26. During this period, the physician emailed on 1/9/26 requesting a status update; LPN/CC F replied that the resident’s vital signs were stable, the resident felt fine, and staff had no further information. LPN/CC F later confirmed that the attached document to the physician’s email was the lab order and that the labs, including UA, should have been collected on 1/9/26 when the order was received. On 1/13/26, a progress note documented that the CNP had ordered CBC, CMP, and UA to be collected that day. LPN/CC F reported collecting the CBC and CMP at 11:31 a.m., but the CMP had to be recollected by the lab the next morning because the initial sample could not be tested. A subsequent note indicated that the day and evening shifts did not obtain a urine sample and that the resident was asleep, so the UA collection was rescheduled. On 1/14/26, the CMP was collected at 8:15 a.m., and LPN/CC F emailed the physician to review the labs; the physician replied that the labs were okay and later stated a UA was not needed unless the resident had symptoms other than odor. There was no CBC report available for review, and documentation showed the CMP was obtained by the clinic. The DON stated she was unsure when the lab order was received but expected labs to be collected the day the order was received if during lab hours. Staff interviews confirmed that physician orders were to be processed immediately and entered into the EMR the same shift they were received, and that resident 5’s labs, including UA, should have been collected on 1/9/26 when the order was received.
Failure to Timely Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required time frame after a cognitively intact resident reported being physically abused by a CNA. The resident, who had a BIMS score of 15 indicating intact cognition, alleged that on the evening of 1/3/26 a CNA verbally assaulted him, slapped him, pushed him into bed, and choked him during provision of care. A scheduled skin assessment on 1/5/26 documented no bruising or finger marks, and later assessment found no signs or symptoms of injury. The resident’s care plan noted a history of making accusatory statements about non-Caucasian staff and a preference for Caucasian staff, with a statement that all such reports would be taken seriously and investigated per policy. On the morning of 1/5/26, during the resident’s bath, he told a CNA that he had been physically abused by the CNA involved on 1/3/26. That CNA reported the allegation to the social services director the same morning. The social services director then reported the allegation to the interdisciplinary team meeting held that day and indicated that, after her report, the matter was to be handled by the administrator. Despite this, the administrator later acknowledged that she did not follow up with the resident on 1/5/26 when the allegation was reported, but instead waited until 1/6/26 to do so. Additional interviews further documented the resident’s repeated reports of the alleged abuse. On 1/8/26, while being checked on by an LPN/care coordinator, the resident again stated that over the weekend a “black lady” CNA had pushed him down on his bed while assisting with care. On 1/9/26, during an in-person interview with a counselor, the resident reported that the CNA became physical with him during his evening cares on 1/3/26, while also stating he had a sense of safety in the care setting and denied feeling intimidated by others. The facility’s abuse policy required that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported to the state survey agency immediately but not later than 2 hours, based on real clock time. The failure to ensure that this resident’s abuse allegation was reported to the state within the required time frame constituted the cited deficiency.
Failure to Implement Wound Treatment Orders and Prevent Pressure Ulcer Development
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, dysphagia, diabetes with neuropathy, and aphasia, was admitted to the facility and identified as being at high risk for developing pressure ulcers based on Braden Scale assessments. The resident was nonverbal, required total assistance for all activities of daily living, and was unable to reposition herself in bed. Initial skin assessments upon admission showed intact skin, but subsequent documentation was lacking until after a hospitalization. On one occasion, a registered nurse documented the presence of two blisters on the resident's buttocks and notified a telemedicine provider (eCare), who gave orders for wound care, including the application of Opti Foam dressings and continued repositioning. However, there was no evidence that these orders were entered into the electronic medical record, implemented, or communicated to the wound nurse, primary care provider, or the resident's representative. There was also no documentation of a skin assessment of the blisters, nor was there evidence of regular repositioning or monitoring as required by the resident's care plan and facility policy. The only documentation related to the blisters was a progress note and a scanned eCare note, neither of which were signed or acknowledged by nursing staff. Interviews with staff revealed confusion and lack of recall regarding the wound care orders and the resident's condition. The facility's skin integrity policy required systematic assessment, documentation, notification, and intervention for skin impairments, but these steps were not followed. As a result, the blisters went untreated for several days, and the resident developed a stage 2 pressure ulcer on her sacrum, which was identified during a subsequent hospital admission. There was no evidence that the required notifications, assessments, or interventions were completed in accordance with facility policy.
Failure to Use Bath Chair Safety Belt Results in Resident Fall
Penalty
Summary
A certified nursing assistant (CNA) failed to use the safety belt on a whirlpool bath chair while bathing a resident who was totally dependent on staff for transfers and mobility. The resident, who had been admitted the previous day, was assisted into the bath chair using a full-body mechanical lift by two CNAs. After the bath, while the resident was still seated in the bath chair, the CNA wheeled the resident away from the tub without securing the safety belt, resulting in the resident sliding out of the chair and falling to the floor. The resident involved had multiple complex medical conditions, including sepsis, pneumonia, epilepsy, neuromuscular dysfunction of the bladder, restlessness, agitation, dysphagia, major depressive disorder, gastrostomy status, encephalopathy, Type 2 diabetes mellitus with neuropathy, aphagia, and acute respiratory failure with hypoxia. The resident was nonverbal at baseline and required total assistance for transfers and bed mobility, as documented in her care plan. At the time of the incident, the care plan specified two-person assistance for transfers but did not yet include specific interventions for bathing safety or the use of the bath chair safety belt. Interviews and observations revealed that, prior to the incident, it was not standard practice or policy at the facility to use the bath chair safety belt for all residents. The CNA involved in the incident was relatively new and did not secure the safety belt during the bath. Other staff confirmed that the use of the safety belt was not routinely enforced before the fall occurred. The safety belt was available and present in the whirlpool bath rooms, but its use was not consistently implemented.
Failure to Protect Residents from Abuse and Neglect by Staff
Penalty
Summary
Multiple incidents occurred in which staff failed to protect residents from abuse and neglect. In one case, a certified nursing assistant (CNA) responded to a resident's request for pain medication in a rude and unpleasant manner, telling the resident she would receive her medication only when her name came up on the nurse's list. When the resident repeated her request, the CNA responded with an unpleasant tone, reiterated her previous statement, and slapped her fist on the door. The resident reported feeling distressed and anxious as a result of this interaction, and subsequently avoided using her call light and experienced increased anxiety when seeing the CNA. In another incident, a certified medication aide (CMA) refused to assist a resident with taking her medication. The resident, who had a history of schizoaffective disorder, trauma, bipolar disorder, and anxiety, requested help with her cup of water while taking her medications. The CMA was reportedly rude and did not want to help with small tasks. After the incident, medication pills and water were found on the floor of the resident's room, and the resident was observed crying and expressing emotional distress. The resident's care plan indicated she required assistance with nutritional needs if her hands were not working properly, but did not specify that staff must remain with her during medication administration. A third incident involved a CNA who, in a joking manner, told a resident he would fight him for a breakfast bar the resident had taken from a snack cart. The CNA's actions escalated, becoming aggressive as he approached the resident in a boxing stance, circled the resident's wheelchair, grabbed the resident's arm, and took the breakfast bar from his hand. The resident, who had severe cognitive impairment, cerebral palsy, and communication difficulties, was assessed and found to have no injuries, but the interaction was verified as inappropriate and aggressive by witnesses.
Failure to Provide Effective Pain Management and Timely Follow-Up
Penalty
Summary
A resident with a history of secondary malignant neoplasm of digestive organs, acute kidney failure, and anxiety disorder experienced increasing abdominal pain and swelling over several days. Despite repeated complaints of pain, visible abdominal swelling, and inability to reposition due to discomfort, the resident reported that her pain was not being adequately controlled and felt that nothing was being done to address her concerns. The resident expressed a desire to see her specialist, and her pain was frequently rated at 6/10, escalating to 10/10 on the day of transfer to the emergency department. Review of the resident's electronic medical record showed multiple administrations of PRN oxycodone and acetaminophen for pain, as well as lorazepam for anxiety. The resident was sent to the emergency department for evaluation of increased abdominal pain, where she received additional pain and anxiety medications. Upon return to the facility, discharge instructions included a follow-up appointment with her primary care physician within two to four days; however, there was no documentation that this follow-up was scheduled or completed, nor was there evidence of follow-up care after the emergency department visit. Progress notes and staff interviews indicated ongoing concerns about the resident's pain, with staff documenting frequent requests for pain medication and persistent high pain ratings. Despite these reports and visible symptoms, there was a lack of documented provider consultation or escalation of care in response to uncontrolled pain, as required by the facility's pain management policy. The deficiency was identified due to the failure to provide effective and appropriate pain management and to ensure timely follow-up and provider involvement for a resident with significant pain and complex medical needs.
Failure to Ensure Timely Medication Administration Due to Inadequate Reordering Practices
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for two residents, resulting in significant medication errors. One resident did not receive five doses of a physician-ordered anti-seizure medication, Zonisamide, due to the medication being on order from the pharmacy and not available for administration. This resident subsequently experienced increased seizure activity, including seizures lasting longer than five minutes, which led to a transfer to the emergency department. Documentation and interviews revealed inconsistent practices among staff regarding when to reorder medications, with some staff waiting until the last dose was administered and others reordering with several doses remaining. The pharmacy was not notified in a timely manner, and the facility's policy required medications to be reordered in advance, with a three-day minimum supply remaining. Another resident did not receive a physician-ordered blood clot prevention medication, Coumadin, for seven days. The missed doses were attributed to a change in the resident's lab schedule, which affected the pharmacy's ability to adjust and supply the medication. The pharmacy was not notified of the updated schedule, resulting in the medication not being reordered or administered during this period. The resident's electronic medical record confirmed the absence of Coumadin administration for the specified days. Interviews with nursing staff and the pharmacy director highlighted a lack of consistent understanding and adherence to medication reordering procedures. Staff reported varying practices for reordering medications, and the pharmacy director noted that medication requests sent by fax on weekends or holidays were not checked, despite the availability of a phone number for urgent orders. The facility's policy and medication reorder sheets instructed staff to reorder medications in advance to prevent missed doses, but these procedures were not consistently followed, leading to the deficiencies identified.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lapses in Safety Procedures
Penalty
Summary
Staff failed to implement adequate interventions and supervision to prevent two residents from eloping without staff knowledge. In the first incident, a resident with a history of left femur fracture, alcohol abuse, tobacco use, and moderately impaired cognition (BIMS score of 12) was able to exit the facility through a patio door that was neither alarmed nor locked at the time. The resident, who required partial to moderate assistance for mobility and used a wheelchair and walker, left his wheelchair on the patio and walked unassisted to a nearby bar to purchase cigarettes. Staff only became aware of his absence after noticing his wheelchair was left unattended, prompting a search and eventual retrieval of the resident from the community. The resident was not wearing a WanderGuard device, and the patio door's alarm system was not in place at the time of the incident. The sign-out procedure was not followed, as the resident did not sign out or notify staff before leaving. In the second incident, another resident with epilepsy, mild cognitive impairment, Alpers Disease, and a history of wandering was found outside the facility without staff knowledge. This resident had a WanderGuard device, but it was placed on the right ankle instead of the left, which prevented the door alarm from activating when the resident exited through the main entrance. The resident was able to move independently in a wheelchair and stated he wanted to go outside to talk to another resident. Staff discovered the resident outside after being alerted by another staff member who saw him from a window. The door alarm system and WanderGuard device were later tested and found to be functional when used as intended, but the improper placement of the device allowed the resident to exit undetected. Documentation showed that elopement risk assessments and care plan updates were not consistently completed or updated in response to changes in the resident's condition and behavior. Interviews with staff and review of facility policies revealed that the sign-out and supervision procedures were not consistently enforced. Residents assessed as safe to leave independently were expected to sign out, while others required staff or family supervision. However, in both incidents, the residents exited without proper notification or supervision, and the required safety devices and procedures were either not in place or not correctly implemented. The facility's elopement/wandering policy defined elopement as any resident exiting the center without staff knowledge, but the policy was not effectively followed in these cases.
Improper Delegation and Inadequate Care Coordination
Penalty
Summary
The provider failed to ensure quality care for a resident whose wound care was improperly delegated by an RN to a CNA. The resident, who was cognitively intact, had a physician's order for specific wound care involving the application of moistened collagen and Optifoam dressing. However, the CNA applied the dressing and ointment, which was not within her scope of practice. The RN admitted to delegating the task to the CNA when busy, which is against the facility's policy and state regulations that require a licensed nurse to perform such tasks. Additionally, the facility did not coordinate hospice care effectively for two residents. One resident developed a pressure ulcer on the coccyx, and the nursing staff did not assess or obtain treatment orders, assuming hospice was managing the wound. The DON was unaware of the pressure ulcer and expected staff to conduct assessments and obtain orders regardless of hospice involvement. This lack of coordination and communication led to inadequate care for the resident. Furthermore, another resident experienced unmanaged pain during repositioning, despite having orders for as-needed pain management. The resident was observed in pain, but the pain assessments documented a score of 0 out of 10, leading to no administration of pain medication. Hospice staff expressed concerns about the facility's management of pain for residents, indicating a failure to recognize and address the resident's pain effectively.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement adequate pressure ulcer prevention and care measures for three residents identified as high risk for skin breakdown. Resident 10 was observed lying in bed for extended periods without repositioning, resulting in stage two pressure ulcers on both heels and an abrasion on the coccyx. Despite having a care plan that included pressure-relieving interventions, these were not consistently applied, and the resident's electronic medical record did not reflect the presence of existing pressure ulcers. Resident 12, who was on hospice care, was also not repositioned regularly, leading to the development of a Kennedy ulcer on the coccyx and an injury on the thigh. The facility staff failed to document these skin impairments in the resident's medical record, and there was a lack of communication with the primary care physician regarding the wounds. The hospice nurse assessed the wounds, but the facility did not have corresponding wound care orders or assessments documented. Resident 49, who was severely cognitively impaired and dependent on staff for mobility, was not repositioned every two hours as required. This resulted in the development of stage two pressure ulcers on the coccyx and buttocks. The facility's Director of Nursing acknowledged that these pressure ulcers were preventable and expressed concerns about the adequacy of staff training and adherence to care protocols.
Inadequate Pain Management for Hospice Resident
Penalty
Summary
The facility failed to adequately manage pain for a hospice resident, identified as Resident 49, who was observed to be in significant discomfort during repositioning. On multiple occasions, the resident was noted to grimace, moan, and shout for help when being moved by staff, indicating unmanaged pain. Despite these observations, the resident's pain was documented as zero out of ten by nursing staff, and no pain medication was administered on the day of the observation, despite having a physician's order for Oxycodone as needed. Interviews with staff revealed that the CNAs and RNs were aware of the resident's increased pain, particularly during repositioning, and had communicated this to the nursing staff. However, the pain management plan was not effectively implemented, as the resident's pain was not adequately assessed or addressed. The hospice RN had previously requested a change to scheduled morphine for better pain control, but this was not reflected in the care provided. The resident's care plan included goals and interventions for pain management, such as administering analgesics as ordered and monitoring for effectiveness. However, the documentation and actions taken did not align with these interventions, as evidenced by the lack of pain medication administration and inaccurate pain assessments. The facility's pain management policy required regular pain evaluations and collaboration with hospice care, which were not sufficiently executed in this case.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to maintain standard food safety practices, as evidenced by unsanitary conditions in the kitchen and improper food storage. During an initial kitchen tour, surveyors observed a fan covered in dust, missing tile flooring, and a large puddle of water under the dishwasher. The dishwasher itself had a significant buildup of limescale and food scum, and the ventilation hood above it was rusted and dusty. The dietary manager admitted to being aware of the ventilation issue and lacked documentation for regular maintenance tasks like deliming the dishwasher. In the main kitchen area, the stovetop range and ovens were found to be dirty, with burnt-on food and grease. Bulk food ingredient bins were unlabeled and undated, and trash cans were left uncovered. The walk-in cooler and freezer had mold growth, damaged flooring, and food items stored improperly, such as raw bacon above milk cartons. Several food items were past their expiration dates or visibly rotting, and the emergency food supply was dusty and expired. During a meal service observation, staff members failed to follow proper hand hygiene and glove use protocols. An unidentified staff person wore the same gloves throughout the service, handling various items and serving food without washing hands. The dietary manager also failed to wash hands between tasks. Temperature monitoring for communal refrigerators was incomplete, with several slots left unrecorded. The facility's policies on food storage, glove use, and temperature monitoring were not adhered to, contributing to the deficiencies observed.
Facility Fails to Maintain Homelike Environment Due to Structural Damages
Penalty
Summary
The facility failed to maintain a homelike environment, as evidenced by significant damages observed in various areas. In a shared bathroom, the ceiling was in disrepair, with bare chicken-wire-type metal sheeting exposed and partially cut out, hanging directly above the toilet. This posed a potential hazard to residents using the bathroom. Resident 9 confirmed that the ceiling had been in this condition for an extended period. Additionally, throughout the building, there were multiple instances of structural damage, including a rusted and corroded emergency exit door frame, missing baseboards, large paint chunks missing from walls, peeling wallpaper, stained caulking, and exposed baseboard heating elements. In the therapy gym, chunks of flooring were missing, and a rubber mat was torn, creating potential tripping hazards. Interviews with staff revealed awareness of some of these issues, but there were delays in addressing them due to scheduling difficulties with contractors. The maintenance director acknowledged the bathroom ceiling issue and the damaged door frame, stating that contractors had been contacted but were unavailable. The interim administrator was aware of the flooring issues and was awaiting funding to address them. The facility's Preventative Maintenance policy, dated July 2008, was reviewed, indicating that the maintenance department was responsible for the condition and function of the physical plant, but it was not effectively implemented to prevent the deficiencies observed.
Infection Control Deficiencies in Wound and Personal Care
Penalty
Summary
The report details multiple deficiencies in infection prevention and control practices at a long-term care facility. A registered nurse (RN) failed to follow proper hand hygiene and wound care protocols while treating several residents with wounds and catheters. The RN did not perform hand hygiene between glove changes and did not use barriers under wound care supplies, which were placed on unclean surfaces. Additionally, the RN did not use enhanced barrier precautions (EBP) or personal protective equipment (PPE) as required for residents with wounds and catheters. Certified nursing assistants (CNAs) also failed to adhere to infection control practices. They did not sanitize their hands before donning PPE and handled clean and contaminated items with the same gloves. This included using the same towels for different parts of a resident's body, which could lead to cross-contamination. The CNAs did not follow proper procedures for personal hygiene and catheter care, increasing the risk of infection for the residents. The facility's environment also contributed to the deficiencies. The whirlpool tub and therapy gym equipment were not maintained in a cleanable condition, with visible dirt and corrosion. The Director of Nursing, who is also the infection preventionist, acknowledged the lack of training and competencies in wound care and infection control among staff. The facility's policies on enhanced barrier precautions and hand hygiene were not consistently followed, leading to potential risks of infection for the residents.
Failure to Update Care Plan for Resident with Pressure Ulcers
Penalty
Summary
The provider failed to revise and update the care plan for a resident with pressure ulcers on both heels and an abrasion on the coccyx. The resident was observed in bed with a catheter and a feet elevation cushion that was not positioned correctly, allowing his heels to touch the bed. Interviews with the RN and DON confirmed that the resident had stage II pressure ulcers on both heels and a superficial abrasion on the coccyx, but these conditions were not reflected in the care plan. The care plan, last updated several months prior, did not include any mention of the current pressure ulcers or abrasions. The facility's policy required that care plans be updated to reflect any new skin impairments, but this was not done for the resident in question. The DON acknowledged the oversight and agreed that the care plan did not reflect the resident's current skin integrity needs. The facility's skin integrity policy outlined procedures for assessing and documenting skin conditions, but the care plan failed to incorporate these updates, leading to a deficiency in care planning for the resident's pressure ulcers.
Deficiencies in Pressure Ulcer Prevention and Infection Control
Penalty
Summary
The provider failed to identify and correct quality deficiencies related to pressure ulcer prevention and treatment, infection control, and pain management. The medical director was aware of some residents having pressure ulcers and completed rounds once a month, but he did not know all the details about the facility's processes and was not aware that the facility lacked a repositioning policy. The director of nursing, who served as the QAPI advisor, acknowledged the need for improvement in infection control, wound care, and enhanced barrier precautions. Additionally, there were issues with the attendance of interdisciplinary team meetings, which were crucial for resident care updates. The facility's QAPI plan included performance improvement projects focused on maintenance, dietary cleaning, labeling, and dating, but did not adequately address the critical areas of pressure ulcer prevention, infection control, and pain management. The QAPI training was not completed by all assigned staff, and there were environmental issues such as missing ceiling tiles, uncleanable surfaces, and dirty equipment in therapy rooms. These deficiencies indicate a lack of comprehensive and effective implementation of the QAPI process to address and monitor critical areas affecting resident care.
Deficiency in Walk-in Cooler and Freezer Maintenance
Penalty
Summary
The provider failed to maintain the walk-in cooler and freezer in a functioning manner that met industry standards. During an observation and interview in the kitchen with the dietary manager, it was noted that the walk-in cooler door did not seal properly, allowing light from the hallway to be visible and creating a gap large enough to poke several fingers through. Additionally, there was an abundance of unidentified black and white fuzzy growth, likely mold, on the walls, door frame, floor, and shelving units, which could be due to improper temperature control. In the walk-in freezer, there was ice buildup on the ceiling and floor, indicating improper temperature control, and a side panel of the condenser was hanging unsecured, blowing hot air and melting the ice buildup. The dietary manager was aware of these issues. Follow-up interviews with the dietary manager were attempted but he was not available.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The provider failed to protect two residents from physical, mental, and verbal abuse by a certified nursing assistant (CNA). The abuse included incidents where the CNA was witnessed kicking a resident in the shin and placing a washcloth over another resident's mouth to quiet them. Both residents involved had dementia, which made it difficult to assess them for psychosocial harm. Despite staff reporting these incidents, the provider allowed the CNA to continue working without taking immediate protective measures. The provider did not conduct a thorough investigation into the allegations of abuse. Although the director of nursing (DON) was informed of the concerns, she did not document any investigation or resident assessments. The executive director (ED) and DON both denied initial knowledge of the abuse allegations, but later confirmed awareness of specific incidents. The provider also failed to report the incidents to the necessary entities in a timely manner, as required by their abuse and neglect policy. The facility's policies and procedures for preventing and responding to abuse were not followed. The DON did not suspend the CNA pending investigation, and the allegations were not reported to the required state agencies. Additionally, the facility's abuse prohibition policy was not adhered to, as the investigation was not documented, and the residents were not adequately protected from further harm during the investigation process.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The provider failed to notify the required entities of allegations of physical, mental, and verbal abuse by a certified nursing assistant (CNA) towards two residents. The provider learned about concerns regarding the care and services a CNA was providing to residents but failed to protect the residents from potential further abuse during the investigation by allowing the CNA to continue working. The provider did not gather more information from the reporting party to understand the extent of the situation and failed to report the incidents to the necessary entities. The CNA was suspended pending investigation, but the initial report to the Department of Health (DOH) was delayed. The provider conducted an investigation into the allegations, including assessing the residents involved for injuries, but nothing was documented. Witness statements from other CNAs indicated that the alleged perpetrator had a history of abusive behavior, which improved temporarily after being addressed by administration but then reverted. The provider failed to conduct a thorough investigation and did not follow their abuse/neglect policy. Interviews with staff revealed that some were aware of the incidents but were initially afraid to report due to fear of retaliation. The Director of Nursing (DON) and Executive Director (ED) were aware of the allegations but did not report them to the required entities. The DON was not aware of the reporting requirements and the provider's abuse and neglect prohibition policy. The provider's failure to report and investigate the allegations promptly and thoroughly led to the deficiency.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The provider failed to thoroughly investigate allegations of physical, mental, and verbal abuse by a certified nursing assistant (CNA) towards two residents. The incidents involved the CNA allegedly kicking a resident in the shin and placing a washcloth over another resident's mouth to quiet them. Both residents involved have dementia, which made it difficult to assess them for psychosocial harm. Despite being aware of these allegations, the provider allowed the CNA to continue working an overnight shift, thereby failing to protect the residents from potential further abuse. The provider did not report the incidents to the necessary entities in a timely manner and failed to conduct a thorough investigation. The initial report to the Department of Health was not submitted until several days after the allegations were first brought to the attention of the executive director (ED) and director of nursing (DON). Interviews with the ED and DON revealed that they were aware of the allegations but did not take immediate action to investigate or report them. The DON admitted to not being aware of the provider's policy on investigating allegations of abuse. The investigation process was inadequate, as the DON only interviewed a small sample of residents and did not document the interviews. The CNA accused of abuse denied the allegations, and the ED and DON felt their investigation was satisfactory despite the lack of documentation and thoroughness. The provider's failure to follow their abuse/neglect policy and to take immediate action to prevent further potential abuse contributed to the deficiency.
Inadequate Administration and Abuse Allegations
Penalty
Summary
The facility failed to ensure the safety and well-being of its residents due to inadequate administration by the Executive Director (ED) and Director of Nursing (DON). The administration did not maintain an effective abuse and neglect prohibition program, as evidenced by their failure to follow policies and procedures related to mandatory reporting and investigations of abuse allegations. Specifically, there were allegations of physical, verbal, and mental abuse by a Certified Nursing Assistant (CNA) towards two residents, which were not reported or thoroughly investigated by the ED and DON. Interviews revealed that both the ED and DON initially denied knowledge of these allegations, and the investigation was insufficient, lacking documentation and comprehensive interviews with staff and residents. Additionally, the facility did not uphold residents' rights to personal privacy. An anonymous staff member used a cellphone to secretly record private resident conversations, intending to provide proof of residents' concerns about their care. This recording was shared with the ED, who was aware of the situation but did not take appropriate action. The failure to protect residents' privacy and address their concerns further highlights the administration's inability to manage the facility effectively. The report also indicates that the DON allowed the implicated CNA to continue working despite being aware of the abuse allegations, potentially putting residents at further risk. The DON was not familiar with the facility's abuse and neglect policy, which required the suspension of staff pending investigation. The divisional director of clinical operations confirmed that the ED was placed on suspension for failing to follow the provider's policy regarding abuse prevention and investigation. The ED was supposed to act as the abuse coordinator, responsible for overseeing the implementation of policies to prevent abuse and neglect, but failed to fulfill these duties.
Violation of Resident Privacy Due to Unauthorized Recordings
Penalty
Summary
The provider failed to uphold a resident's right to personal privacy for at least three residents due to an anonymous staff member using their cellphone to secretly record private resident conversations. The South Dakota Department of Health received a complaint detailing allegations of abuse by a certified nursing assistant (CNA), which included audio recordings of private conversations of residents. The anonymous staff member recorded these conversations to gather evidence of the alleged abuse to present to the administration. Interviews with the director of nursing and the executive director revealed initial denials of any recent allegations of abuse or neglect by staff. However, upon further questioning, the executive director acknowledged that a staff member had mentioned concerns about a CNA being rough with residents. The anonymous staff member who made the recordings confirmed that they had shared the recordings with the executive director, although the executive director did not initially mention the recordings. The provider's policies, including the employee handbook and code of conduct, prohibit unauthorized recordings and emphasize the importance of maintaining resident privacy. The anonymous staff member was placed on suspension pending investigation for secretly recording resident conversations, which violated the Health Insurance Portability and Accountability Act (HIPAA) and the company's policies. The staff member had been trained on resident rights, HIPAA, and abuse prohibition, and had acknowledged receipt of the employee handbook and code of conduct.
Failure to Investigate Elopement of At-Risk Resident
Penalty
Summary
The provider failed to ensure a thorough investigation was completed for a resident identified at risk for elopement who successfully left the facility without staff knowledge. The resident, who had a history of dementia with behavioral disturbances and was an active exit seeker, was found approximately a half mile away from the facility and returned by staff. Despite having a Wanderguard device that was functioning and monitored every shift, the resident managed to exit the building when a wheelchair transit driver entered a code to return another resident from an appointment. Staff misinterpreted the situation, assuming the alarm was related to the transit activity, and turned off the alarm. The resident had been assessed as at risk for elopement on multiple occasions and had a history of frequent attempts to leave the facility. His medical records indicated moderate cognitive impairment, and he had been actively seeking exits, as noted in various care conference notes and alert charting. Despite these indicators, the facility's response to the alarm was inadequate, leading to the resident's unsupervised departure. The incident was reported the following morning at a staff meeting, and it was noted that the resident was found pushing his wheelchair several blocks away from the facility. Interviews with staff revealed a lack of clarity and communication regarding the elopement incident. The Director of Nursing, who had recently assumed the role, acknowledged the need for a more thorough investigation and had heard conflicting reports from staff about the incident. The facility's elopement policy defined elopement as a resident exiting the center without staff knowledge, which occurred in this case. The deficiency highlights a failure in the facility's procedures to prevent and adequately respond to elopement risks, particularly for residents with known cognitive impairments and exit-seeking behaviors.
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Two residents experienced failures in timely implementation of physician orders and provider notification. One resident with cognitive impairment, respiratory failure, pneumonia, and a urinary catheter had a UA/UC ordered after increased confusion, but catheter change and urine collection were delayed and inconsistent, and an antibiotic order faxed for a UTI was left on a reception fax machine and never started before a later order changed therapy based on culture results. Lab reports showing Enterobacter cloacae and susceptibility to a different antibiotic were not consistently documented as reviewed, and the resident continued to exhibit confusion and flank pain until transfer to the ER. Another resident with ESRD on dialysis, hypotension, hypertension, and heart failure had orders for Midodrine with BP parameters and daily Metoprolol, but Midodrine was not given on dialysis mornings and Metoprolol was rarely given on dialysis days, without notifying the physician. Very low BPs were recorded without documented provider notification or repeat checks, despite a TAR requiring monitoring for post-dialysis complications. Interviews and policy review showed expectations to follow orders and notify physicians of abnormal labs, omitted medications, and changes in condition, which were not met in these cases.
Two residents at high risk for pressure ulcers did not receive consistent, individualized prevention and treatment measures, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment and high Braden risk, fully dependent on staff for mobility and hygiene, was repeatedly observed in bed with the head of bed elevated and sliding down, without documented q2h repositioning, individualized pressure-relief interventions, or consistent use of barrier cream, and CNAs and restorative staff were unaware of specific pressure-prevention measures for her. Another resident with multiple comorbidities, prior healed pressure ulcers, and a high Braden score developed recurrent stage II and III pressure ulcers to the coccyx and gluteal fold, a left heel DTI, and a left lateral leg stage II ulcer; ordered wound treatments were not documented as completed on at least one ordered date, he was not on a defined turning schedule despite being largely bedfast, and heel offloading and use of heel boots were inconsistently implemented and documented. In both cases, staff interviews and record review showed that facility practices did not consistently align with the facility’s own skin and pressure injury prevention policy requiring q2h repositioning, appropriate support surfaces, and systematic offloading for bedfast residents.
The deficiency centers on unsafe resident transfers and unsecured chemicals. A resident with hemiplegia and severe cognitive impairment, care planned for a one-person sit-to-stand (STS) lift transfer, was instead manually transferred by a CNA without the lift, during which the resident’s legs gave out, he was lowered to the floor, hit his head, and later was found to have a subdural hematoma. Another resident with severe cognitive impairment and documented inability to meet STS criteria was nonetheless assessed and care planned for STS transfers, while staff and family intermittently pivot transferred her without a gait belt and with inconsistent use of mechanical lifts, amid reports that pocket care plans and Kardex information were not kept up to date. Additionally, surveyors repeatedly observed an open tub room with unlabeled and labeled chemical spray bottles accessible on the tub, and an unattended housekeeping cart in the dining room with toilet bowl cleaner and other disinfectants unlocked and reachable by residents, contrary to staff statements that such rooms and chemicals were to be secured.
The facility failed to consistently honor resident preferences and care‑planned frequency for bathing, resulting in multiple residents going six to ten days or longer between baths despite being scheduled for twice‑weekly showers or baths. Several residents, including those with impaired and intact cognition, reported missed or inconsistent baths, needing to repeatedly remind CNAs, and being told they were skipped due to other residents waiting longer, staffing shortages, or equipment issues. Observations included a resident with long, jagged fingernails and urine odor who reported missed scheduled showers. Review of EMRs and the bath schedule showed numerous missed baths without documented refusals or valid reasons, while the grievance log and resident council minutes documented ongoing complaints from multiple residents about not receiving baths as scheduled. Nursing staff acknowledged receiving complaints and that residents sometimes went more than a week without bathing, despite a facility policy stating residents have the right to choose timing and frequency of bathing and requiring documentation of bathing activity or refusals.
Two cognitively intact residents with significant ROM and mobility limitations did not receive their care-planned restorative nursing programs as ordered. One resident with DM, neuropathy, above-knee amputation, and CKD reported increasing stiffness and weakness and stated that staff no longer brought her for exercises; records showed only sporadic lower extremity and kinetic bike sessions over several months despite physician orders and a care plan for regular AROM and restorative activities. Another resident with RA, polyneuropathy, and prior fractures, who used a power wheelchair, reported not receiving her prescribed exercise program and feeling she was losing strength; her MDS and restorative documentation showed no completed restorative exercises or standing with a walker despite a detailed restorative care plan. Therapy staff and RAs confirmed written restorative recommendations and expectations for 3–6 sessions per week, but reported that two RAs were responsible for about 44 residents, could not see all residents daily, prioritized those more willing or independent, and were unsure when these two residents last received restorative exercises, while the DON acknowledged awareness of staffing difficulties and confirmed the minimal restorative services actually provided.
Staff failed to maintain dignity, hygiene, and privacy for multiple dependent residents. A resident with severe cognitive impairment and depression was left in bed in nightclothes with dried food and juice on her body and linens, and was observed with a dried substance on her nose that was not cleaned over time, despite her reliance on staff for all personal care. Another cognitively impaired resident, dependent on staff for hygiene and dressing, was repeatedly observed wearing a heavily soiled shirt, with food in his beard and thick residue on his fingers, and continued to spill coffee on himself in the dining room without staff assistance or interventions; there was no documentation that he refused care. A third cognitively impaired resident with severe mental illness and risk for abuse and neglect was provided incontinence care while standing at the sink in a shared room without adequate use of the privacy curtain or window blinds, allowing his roommate and potentially others to see him during intimate care, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment, dementia, metabolic encephalopathy, a history of stage II pressure ulcers, and a urinary catheter was left in a dining room for about ten hours without receiving care as outlined in the care plan. The resident’s plan required repositioning every two hours, substantial assistance with toileting hygiene every two to three hours, monitoring of urine output each shift, and extensive assistance with transfers and wheelchair mobility. On the day of the incident, the resident was brought to the dining room in the morning and not returned to his room until evening, and the assigned CNA and LPN did not provide the scheduled care during this time. The facility’s investigation determined that this failure to follow the care plan and provide necessary care for an extended period constituted neglect.
A resident with a history of making allegations of rough care and a care plan requiring all care to be provided by two caregivers was assisted by a single CNA, contrary to the documented "cares in pairs" intervention. The care plan identified manipulative behavior and alleged mistreatment, and specified that two caregivers should be present to address the resident’s needs and observe the entire care session. On one occasion, the CNA entered the room alone and began providing care, after which the resident reported to an LPN that the CNA had been rough, leading to a deficiency citation for failure to follow the resident’s care plan under F684.
Two residents who required two-person assistance with mechanical lifts were subjected to unsafe transfers when CNAs used improperly sized, mispositioned, or incompatible full-body slings and did not follow manufacturer instructions. In one case, a resident newly admitted with a hospital-provided sling was lowered to the floor during a lift transfer after sliding forward in the sling, resulting in reported rib pain but no fractures on X-ray. In another case, a resident’s wheelchair pad and handle became entangled in a large sling during a lift, causing the wheelchair and resident to be lifted off the floor; the sling remained incorrectly positioned at mid-back when the resident was lifted again and moved to bed. Multiple CNAs and nurses reported no recent facility-specific training or competencies on mechanical or sit-to-stand lifts, selected sling sizes by guessing based on body type or using whatever sling was in the room, and lacked clear, updated care plan or Kardex documentation specifying lift type and sling size for residents who required mechanical lifts.
A resident with moderately impaired cognition, Parkinson’s disease, dementia, high fall risk, and moderate pressure-ulcer risk, who required a sit-to-stand lift and maximal assistance for toileting and hygiene, was taken to a beauty shop bathroom by a CMA and left unattended with the lift attached, the door closed, and no call light activated. The resident was later found by a nurse after an extended, unknown period and had transient redness on the buttocks consistent with prolonged sitting. Documentation lacked a post-incident pain and skin assessment. Staff interviews showed there was no clear, consistent process for how often CNAs should check on residents left on toilets, and an observation revealed a staff member failed to change the beauty shop door sign to indicate occupancy, all occurring under a facility neglect policy that defines neglect as failure to provide necessary goods and services to avoid harm.
Failure to Follow Physician Orders and Notify Providers for Infection Management and Dialysis-Related Care
Penalty
Summary
The deficiency involves failures to follow physician orders in a timely manner and to notify providers of significant clinical information for two residents. For one resident with moderate cognitive impairment, respiratory failure, pneumonia, and an indwelling urinary catheter, the physician ordered a UA/UC after the resident’s son reported increased confusion and requested urine testing. The order for catheter change and urine collection was received and noted, but the catheter change documented on the treatment record as due on one date was not completed until early the next morning. Lab reports show urine samples collected on two different dates and times, with one sample having been collected and then recollected. The resident’s son reported being told that a urine sample had sat in the refrigerator too long and had to be recollected, and that the facility did not start the initially ordered antibiotic while the culture was pending. The lab ultimately reported Enterobacter cloacae complex in high colony counts, and the physician ordered cefuroxime, then later discontinued it and ordered nitrofurantoin based on susceptibility results. The cefuroxime order, faxed on a Friday, was not implemented because it remained on a fax machine in the front reception area over the weekend and was not found until the following Tuesday, at the same time the later order to stop cefuroxime and start nitrofurantoin was found. The cefuroxime order was not noted as reviewed by staff, and the preliminary and final culture reports, including susceptibility results showing the organism was not susceptible to cefuroxime but was susceptible to nitrofurantoin, were not consistently documented as reviewed with clear dates and staff identifiers. Progress notes document ongoing confusion, flank pain, and the resident’s belief that there was urine in her oxygen tubing, as well as the son’s concerns and request for transfer to the emergency room. The DON later documented that her investigation found the 7/11 cefuroxime order had not been started because it was discovered only when the 7/15 order to stop it and start nitrofurantoin was located, and interviews revealed uncertainty about why the UA was recollected and that the incident investigation did not address the delayed UA collection or lack of on-call physician notification for preliminary lab results. For a second resident with intact cognition and diagnoses including ESRD on dialysis, hypotension, hypertension, and heart failure, physician orders directed dialysis three times weekly, Midodrine three times daily for hypotension with a parameter to hold if SBP was 120 or greater, and daily Metoprolol Succinate ER for hypertension without hold parameters. The March MAR shows the resident did not receive Midodrine on the mornings of dialysis days and received Metoprolol only once on a dialysis day during a specified period, with no documentation that the physician was notified of these omissions. Dialysis records show pre-dialysis BPs in the low-normal range, and the MAR documents very low BPs on one evening and the following morning, with no documentation that the provider was notified of these low readings. The TAR required monitoring for post-dialysis complications, including hypotension symptoms, twice daily on dialysis days, but only one day in the month reflected documented symptoms. Interviews with nursing staff and the DON confirmed expectations that physician orders be processed within the shift, that abnormal labs and out-of-parameter vitals be reported, and that Midodrine be given before dialysis when within parameters, but also revealed uncertainty about processing timelines, lack of a facility policy on vital sign parameters, and that the physician was not notified about the inconsistent administration of Midodrine and low blood pressures. Facility policies required following all physician orders and notifying the physician when orders were not followed or when there was a significant change in status, but these were not adhered to in these cases.
Failure to Implement Individualized Pressure Ulcer Prevention and Treatment for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and individualize pressure ulcer prevention and care for two residents at high risk for skin breakdown, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment, diabetes, depression, and high Braden risk was dependent on staff for hygiene, repositioning, and transfers. On admission, she had no skin breakdown but was identified as at risk. Her care plan initially addressed potential skin impairment but did not include individualized repositioning or pressure-relief interventions beyond standard admission practices. Staff and leadership later acknowledged that the pressure ulcer prevention measures in place before her ulcer developed were standard for all admissions and not tailored to her specific risk factors. For this resident, documentation showed blanchable redness to the buttocks on a skin assessment, followed by identification of a facility-acquired abrasion to the left buttock and coccyx and additional undescribed areas on the backs of both thighs. The next day, the abrasion on the left buttock was documented as a stage II pressure ulcer, which later increased in size. Observations on multiple days showed the resident lying in bed on her back with the head of the bed elevated and her body bent at the chest, with staff acknowledging that this positioning increased the risk of shearing when she slid down in bed. Interviews revealed that she could not turn herself in bed and required staff assistance for repositioning, yet there was no documentation that she was turned every two hours, and the DON could not find evidence that she refused repositioning or barrier cream. CNAs and a restorative aide reported not knowing what pressure prevention interventions were in place for her, and one CNA left her in bed all day because the resident did not respond when asked if she needed anything, despite the resident’s inability to use the call light or reposition herself. The second resident had multiple serious medical conditions, including spinal stenosis, chronic kidney disease, atherosclerotic heart disease, dysphagia, and protein-calorie malnutrition, and was assessed as high risk for pressure ulcers on the Braden scale. He had a history of multiple pressure ulcers and other wounds that had previously healed, but subsequent skin evaluations documented recurrent redness and pressure areas, including a right gluteal fold pressure ulcer and coccyx involvement. Progress notes identified a bleeding open area under the right buttock, reclassification of a right gluteal fold lesion from MASD to a pressure ulcer, and later documentation of a large coccyx pressure area, a left lateral heel DTI, and a left lateral lower leg stage II pressure blister. His care plan listed multiple active pressure injuries and interventions such as an air mattress, pressure-redistributing cushions, wound treatments, and weekly wound monitoring. Despite these identified wounds and orders, the record showed that ordered wound care treatments were not documented as completed on at least one ordered date, and the DON agreed that if treatments were not signed as completed, they were not done, and that wounds would worsen if treatments were missed. Interviews with nursing leadership and the wound nurse indicated that the resident was not on a formal repositioning schedule, even though standard practice was to reposition residents every two hours, and that his heels were offloaded and repositioned only “as needed.” Staff reported that he often refused to get up in his wheelchair and refused heel lift boots, but refusals and effective approaches were not consistently documented. A PA-C stated she would expect preventative measures such as an air mattress to prevent recurrence of pressure ulcers, and the DON and RN unit manager confirmed that an air mattress was ordered only after multiple pressure injuries were documented. The facility’s own Skin and Pressure Injury Prevention Program policy required offering repositioning at least every two hours for bedfast residents, considering off-loading when the head of bed was elevated, and using special mattresses as indicated, but the documented care and staff interviews showed gaps between these policy requirements and the actual implementation of pressure ulcer prevention and treatment for this resident. Overall, for both residents, surveyors identified failures to consistently implement and document individualized pressure ulcer prevention measures such as scheduled repositioning, appropriate use of pressure-relieving surfaces, barrier creams, and heel offloading, as well as failures to ensure staff understood and followed care plan interventions. These failures occurred despite both residents being clearly identified as high risk for pressure injury and, in the second case, having a documented history of prior pressure ulcers and multiple active wounds.
Unsafe Transfers and Unsecured Chemicals Leading to Resident Injury and Exposure Risk
Penalty
Summary
The deficiency involves failures to ensure safe transfers in accordance with resident care plans and to secure hazardous chemicals from resident access. One resident with hemiplegia following a stroke and severe cognitive impairment, who was care planned to transfer with one staff using a sit-to-stand lift, was transferred by a CNA without the lift from the toilet to a wheelchair. During this transfer, the resident’s legs gave out, he was lowered to the floor, and his head struck the wall, resulting in a skin tear on his left forearm, a bump on the back of his head, and elevated blood pressure and pulse. A CT scan later revealed a subdural hematoma. The DON reported that the CNA had been educated that same morning on the importance of following resident care plans, and the CNA stated she did not use the stand lift because she believed she could complete the transfer faster without it. A second resident with senile degeneration of the brain and severely impaired cognition was also not consistently transferred according to her assessed needs and care plan. Her care plan initially indicated use of a sit-to-stand lift, but a lift assessment documented that she could not bear at least 50% of her weight on one leg, could not sit upright without physical assistance, and could not follow simple instructions, which meant she did not meet the criteria for a sit-to-stand lift. Despite this, the assessment summary still indicated she was to use a sit-to-stand lift for bed-to-chair transfers, and she was care planned to use a sit-to-stand lift until later revised to a full-body mechanical lift. The resident’s family member reported concerns about transfers, including that staff did not use a gait belt, that she had assisted staff with pivot transfers, and that staff sometimes used a sit-to-stand lift and sometimes pivot transferred the resident with two staff. A CNA/CMA described pivot transferring this resident with the assistance of the family member by placing their arms under the resident’s arms and moving her from bed to a bath chair, during which the resident did not follow directions or move her feet, and the CNA/CMA held the resident up while quickly pulling the bath chair under her. Documentation and communication tools used by staff to determine transfer methods were not consistently accurate or up to date. Staff reported relying on the Kardex and pocket care plans to determine how residents should be transferred, and multiple staff acknowledged that pocket care plans were not always kept current. For the second resident, the pocket care plan at one point indicated she was a pivot transfer with one staff, while her family stated she required at least two staff for a pivot transfer and had previously used a mechanical lift in another facility. Later, the undated pocket care plan for her hallway indicated she was to be transferred with a full-body mechanical lift and sling. The DON and administrator confirmed that the initial lift assessment for this resident showed she was not a candidate for a sit-to-stand lift, yet she was care planned to use one. The deficiency also includes unsecured hazardous chemicals accessible to residents in a bathtub room and in the main dining area. On multiple observations, the blue hallway bathtub room door was open with no staff present, and a pink crate on top of the bathtub contained two spray bottles, one labeled Multi-Surface Peroxide cleaner with warnings that it causes skin irritation and serious eye damage, and another unlabeled bottle two-thirds full of an unknown liquid. Staff, including a CNA and RN, stated the bathtub room doors were supposed to be closed and locked to prevent resident access and exposure to unsecured chemicals, and the DON and regional nurse consultant confirmed the presence of the labeled and unlabeled chemicals and that the unlabeled bottle did not contain water. In the main dining room, an unattended housekeeping cart was observed with residents present and no staff nearby. The cart contained an open bottle of toilet bowl cleaner on an unlocked portion of the cart, and additional chemicals, including Multi-Surface Peroxide cleanser and Micro Kill foaming disinfectant cleaner, were stored in a lockable compartment that was left unlocked, with the keys on top of the cart. The administrator verified that the chemicals were not secured from resident access and that the bathtub room was supposed to be closed, locked, and accessible only by staff, and that chemicals were expected to be stored in their original labeled containers in a secure location.
Failure to Honor Resident Bathing Preferences and Scheduled Bathing Frequency
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor residents’ rights to choose and receive bathing at the frequency specified in their care plans and preferences. Multiple residents who preferred bathing at least twice weekly did not consistently receive baths or showers as scheduled, and staff did not consistently document refusals or reasons for missed baths. For one resident with severely impaired cognition, the care plan dated 3/25/26 indicated a preference for two baths per week, yet electronic records from 1/28/26 through 3/25/26 showed she received a bath on 3/9/26 and 3/16/26, refused on 3/13/26, was marked as “not available” on 3/20/26 without any supporting documentation that she was out of the facility, and had no documentation of being offered or receiving a bath on 3/23/26. A family member reported concerns that this resident had only received one shower since admission and raised these concerns to the administrator. Another resident with moderately impaired cognition had a care plan dated 3/25/26 indicating a preference for two baths per week. The bath schedule showed he was to receive baths or showers twice weekly on specific days, and there was no documentation of refusals. However, bathing records from 1/28/26 through 3/25/26 showed gaps of six and seven days between some baths, including a seven‑day interval before a bath on 2/21/26 and a six‑day interval before a bath on 3/13/26. This resident reported that there were times he did not receive a bath for a week, that he had to repeatedly remind staff to get a bath, and that the days he was bathed were inconsistent, sometimes occurring every other day and other times with a week between baths. A cognitively intact resident with a care plan preference for two baths per week was scheduled for baths on two specific days each week, but bathing documentation showed missed baths on multiple dates with no refusals recorded. As a result, there were intervals of seven and ten days between baths. This resident stated he did not receive the showers he was supposed to and was unsure if he would receive a scheduled shower on the day of interview. Another resident with moderately impaired cognition, whose care plan indicated a preference for two to three showers per week and who was scheduled for showers on Sundays and Thursdays, had multiple missed showers without documented refusals and repeated six‑day gaps between bathing. During observation and interview, this resident had long, jagged fingernails, smelled of urine, and reported that showers were sometimes not provided on scheduled days or were changed, and that staff had told him he would not get a shower because the shower was being repaired. The facility’s own bath schedule listed specific days for each of these residents to receive baths or showers, but documentation and resident interviews showed that these schedules were not consistently followed. The grievance log from November 2025 through March 2026 recorded multiple resident complaints and resident council concerns about not receiving baths or showers as expected, including reports from several residents that they had gone extended periods without bathing and that staff told them they were being skipped because other residents had waited longer or due to staffing issues. During a resident council interview, several residents reiterated that baths were not completed as scheduled and described waiting from eight days up to three weeks between baths, as well as equipment issues such as a broken chair that prevented bathing. Nursing staff, including an RN and a restorative aide, acknowledged receiving complaints that residents were not getting baths as scheduled and stated that residents sometimes went more than a week without a bath, and that missed baths could contribute to odors, dignity concerns, and skin conditions. The DON stated she expected residents to be bathed according to their care plan preferences and that refusals should be documented, but she was aware of prior grievances about missed baths. The facility’s bathing policy stated that residents have the right to choose the timing and frequency of bathing and required documentation of bathing activity or refusals and reapproach after refusals, but the documented patterns and interviews showed that these requirements were not consistently met.
Failure to Provide Planned Restorative Nursing Programs for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide ongoing restorative nursing programs as care planned and ordered for two cognitively intact residents with limited ROM and mobility. One resident, with Type 2 DM with diabetic neuropathy, an above-knee amputation, adjustment disorder with depressed mood, and stage 4 CKD requiring dialysis three times weekly, reported frustration that the fingers on her right hand were stiff and that she could no longer make a fist. She stated she felt weaker and believed she was not receiving the exercises she needed, explaining that she previously had exercises but no longer was brought for them. She reported that when she complained to therapy about not getting her exercises, she was told that restorative nursing aides were now responsible for providing them. Record review for this resident showed a physician note directing staff to encourage participation in restorative activities and a physician’s order for staff to encourage restorative activity three times weekly with a progress note to be completed on day shift when done. Her care plan included participation in restorative therapy with a goal to maintain current functional ability and interventions of AROM per therapy and nursing recommendations. Her MDS documented functional limitations in ROM in one upper and one lower extremity and indicated she received only two days of AROM restorative nursing programs in the seven-day look-back period. Restorative documentation from mid-December through late March showed that for lower extremity exercises she was documented as not available on multiple days, refused on several days, and not applicable on others, with only two days of restorative lower extremity exercises provided. For kinetic bike exercises over a three‑month period, she was documented as not available or refusing on multiple days, with several days marked not applicable, and only four days of kinetic bike restorative exercises completed. A second resident, who used a power wheelchair, had limited use of upper and lower extremities, and diagnoses including rheumatoid arthritis, polyneuropathy, and fractures of the right lower leg and foot, reported via an iPad translation device that she had participated in PT on admission and was discharged to a restorative program. She stated she was upset that she had not been receiving her exercise program, had complained to the DOR, and felt she was losing strength and her ability to stand and transfer. Her BIMS score indicated she was cognitively intact. Her MDS showed functional limitation in ROM in one lower extremity and no restorative nursing exercise programs received. Her care plan called for participation in a restorative therapy program to maintain functional abilities, with interventions including AROM, sitting exercises with a 3‑lb green TheraBand, trunk exercises x15 reps, and transfers involving standing with a walker up to 10 minutes. Restorative documentation from late January through late March showed multiple refusals and days marked not applicable, with no documentation that she received lower extremity exercises or stood with her walker for ten minutes during that period. Interviews with therapy staff and restorative aides revealed that therapy had provided written restorative recommendations on transfer forms, and the DON was responsible for setting up the programs. The therapy team expected two restorative aides to complete the recommended exercise programs, including upper and lower extremity exercises three to six times per week for the first resident (arm bike, recumbent kinetic bike, 5‑lb weights, green bands) and a lower extremity program three to six times per week for the second resident (standing with walker for ten minutes, 3‑lb weights, green bands). One restorative aide reported that she and the other aide were responsible for restorative exercises for about 44 residents, each scheduled for 15 minutes daily, and that it was impossible to see all residents when only one aide was working. She stated some residents were prioritized because they were ready, independent in getting to the exercise room, and enjoyed exercising, while others known to refuse were deprioritized when staff were busy. She acknowledged not having completed restorative exercises with the first resident recently and not having done restorative exercises with the second resident in over a month. The other restorative aide confirmed workload challenges, restrictions on being alone with the first resident, difficulty coordinating use of the main therapy room and equipment, and uncertainty about when either resident last received restorative exercises. The DON and regional nurse consultant confirmed that the facility’s policy defined restorative nursing as interventions to promote optimal functioning, that residents with written programs were expected to receive at least 15 minutes per day, and that the first resident had received only seven days of restorative exercises since mid‑December while the second resident appeared to have received none since late January, and they were unaware of the residents’ concerns.
Failure to Maintain Resident Dignity, Hygiene, and Privacy During Personal Care
Penalty
Summary
The deficiency involves failures to maintain resident dignity, hygiene, and privacy for multiple residents who were dependent on staff for personal care. One resident with severely impaired cognition, depression, and senile degeneration of the brain was dependent on staff for dressing, personal hygiene, and transfers with a full body lift. Her care plan required staff to use yes/no questions and clear explanations due to her communication difficulties. Her family reported concerns that she was not being changed regularly, was left in bed in her nightgown until mid-afternoon, and was not assisted out of bed to the dining room for meals. The family also reported finding dried juice on the resident’s stomach and bed sheets on consecutive days, indicating the linens had not been changed, and later finding the resident in bed around mid-afternoon in pajamas with food on her face and clothing. During the survey, the resident was observed in the afternoon with a dried green substance on her nose that remained there over an extended period, despite her dependence on staff for hygiene. Another resident with severely impaired cognition, unclear speech at times, and dependence on staff for personal and oral hygiene and dressing was repeatedly observed with soiled clothing and unclean hands and face. He was first seen lying in bed wearing a white shirt with multiple brown discolorations on the chest and arms. Later the same day, he was observed in the dining room wearing the same soiled shirt and spilling coffee repeatedly onto his clothing protector and shirt without staff offering assistance or interventions to prevent further spillage. That afternoon, he was again observed in bed wearing the same dirty shirt with food in his beard and stated he would have liked staff to change his shirt and that he had trouble with spilling food and drinks and wanted more assistance with eating and drinking. On another day, he was observed twice in the hallway with food in his beard and a thick orange substance on his fingers around his fingernails, as well as food on his shirt, with no indication in the record that he had refused clothing changes or hand and face washing. A third resident with severely impaired cognition, depression, anxiety, and a care plan noting severe mental illness with risk for abuse and neglect did not receive adequate privacy during incontinence care. Two CNAs assisted this resident in his shared room by placing a gait belt, helping him stand at the sink, lowering his pants, removing his incontinence brief, cleaning his private areas, and applying a new brief while his roommate was in bed. The privacy curtain was not pulled far enough to prevent the roommate from seeing the resident, and the window blinds were open, leaving him exposed during personal care. Staff interviews confirmed that residents’ clothing should be changed when soiled, faces and hands washed after meals or when soiled, refusals documented, and privacy ensured by closing doors, blinds, and curtains during personal care. The observations and interviews showed that these expectations and the facility’s dignity and privacy policy were not followed for these residents.
Resident Left in Dining Room for Extended Period Without Required Care
Penalty
Summary
The deficiency involves a resident with severe cognitive impairment who was left in the dining room for approximately ten hours without receiving care as outlined in his care plan. According to the SD DOH Facility Reported Incident, the resident was brought to the dining room at around 8:30 a.m. and was not taken back to his room until 6:31 p.m. that day. During this period, the resident did not receive identified interventions to meet his care needs from the CNA and LPN assigned to him. The facility’s investigation determined that the resident was neglected because his care plan was not followed and necessary care was not provided for an extended period. The resident’s medical record showed he had a BIMS score of 1, indicating severely impaired cognition, and diagnoses of metabolic encephalopathy and dementia. His care plan documented that he was at risk for skin impairment due to a history of stage II pressure ulcers, required repositioning every two hours and as needed, had a urinary catheter with urine output to be documented each shift, and required substantial assistance with toileting hygiene every two to three hours, transferring, and wheelchair mobility. He was also identified as being at risk for falls and was to be treated with respect and dignity and to reside free of mistreatment. Despite these documented needs, the resident remained in the dining room for about ten hours without the planned care being provided. The FRI report noted that the resident had a urinary catheter, could move and readjust himself in his wheelchair, was forgetful, and needed staff assistance with using the bathroom. Although his skin assessment after the incident did not show skin breakdown related to the event and he was not incontinent of bowels, the facility’s investigation concluded that the failure of the assigned CNA to follow the care plan and provide care during the prolonged period in the dining room constituted neglect. Interviews with the DON confirmed that the facility’s investigation found the resident had been neglected by staff on that day because his care needs, as specified in his care plan, were not met for approximately ten hours.
Failure to Follow Care Plan Requiring Two Caregivers During Resident Care
Penalty
Summary
Non-compliance at F684 occurred when a resident who was care planned to receive all care from two caregivers at all times was assisted by a single CNA. The resident had a documented history of making allegations of staff being rough and was identified in the care plan as requiring "cares in pairs" with two caregivers present to address her needs and observe the entire care session. Despite this, the CNA entered the resident’s room alone and began providing care without a second staff member present, contrary to the resident’s care plan and the facility’s expectations. The resident’s care plan, initiated on 10/28/22, identified manipulative behavior and alleged mistreatment as focus areas, noting that the resident might voice allegations of mistreatment or exploitation by caregivers, related to feelings of loss of independence, and might use abusive language. Interventions included assuring the resident she was safe and secure, providing two caregivers to address her needs and observe the entire session, having supervisory personnel observe care delivery as much as possible, and offering staff of certain racial backgrounds when able, based on the resident’s stated preferences and history of accusations. On the date of the incident, the resident reported to an LPN that the CNA had been rough with her during care that was provided without a second caregiver present. Staff interviews confirmed that the resident was known to make accusations, tell inconsistent stories, and sometimes scream even before being touched, and that she was to always receive care with two staff present because of these behaviors and prior allegations. On the day of the incident, staff on duty reported hearing the resident screaming after the CNA entered the room and began helping her, then left to get a second person to assist. The CNA acknowledged going into the room alone and assisting the resident with care, thereby not following the resident’s care plan requirement for two caregivers to be present during care, which led to the cited deficiency under F684.
Improper Mechanical Lift Use and Inadequate Sling Selection for Dependent Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of total body mechanical lifts and appropriate slings for residents requiring two-person assistance for transfers. Contracted travel CNAs and facility CNAs used incompatible or improperly sized and positioned slings, and staff lacked clear, accessible information on which sling size and type to use for specific residents. Surveyors identified that staff often selected sling sizes based on visual estimation of body size or by using whatever sling was present in the room, rather than following resident-specific guidance. Care plans and Kardexes for multiple residents who required mechanical lifts did not specify the type of lift (full body or sit-to-stand) or the correct sling size, leaving staff without written direction. One incident involved a resident who had been admitted earlier that day with a full body lift sling brought from the hospital. During a transfer from wheelchair to bed using a full body lift, two CNAs attached the sling provided by the family and began the transfer. As one CNA attached the lower body sling straps to the lift hooks, the resident moved and slid forward in the sling. The CNAs readjusted the resident and completed attaching the sling, but the resident continued to move and slid toward the edge of the wheelchair seat, causing the sling to tilt downward. Unable to safely complete the transfer, the CNAs lowered the resident to the floor using the upper portion of the sling while the lower portion remained attached to the lift. The resident’s buttocks contacted the floor first, she was then assisted to a lying position, and she reported rib pain; a subsequent chest X-ray showed no breaks or fractures. This event was identified as the start of Immediate Jeopardy at F689. Another observed incident involved a different resident being transferred from a wheelchair to a bed using a full body lift and a burgundy (large) sling. Two contracted travel CNAs placed the sling behind the resident, pulled the lower straps under her thighs, and interlaced the straps. As they began lifting, the resident’s wheelchair pad and the left handle of the wheelchair became caught in the sling, causing the wheelchair to lift off the floor with the resident still seated. While the resident and wheelchair were suspended, one CNA pulled on the wheelchair pad to free it, and the CNAs switched tasks while the resident remained in the air. After lowering the resident and wheelchair back to the floor and freeing the wheelchair handle, they did not reposition the sling, which was noted to be placed too high, with the bottom of the sling at the resident’s mid-back instead of under her buttocks. They then lifted the resident again and transferred her to the bed, with one CNA stating during the lift that the setup was “all wrong.” Interviews with multiple CNAs and nursing staff revealed that many had not received recent or any facility-specific training or competencies on safe use of mechanical lifts and sit-to-stand lifts. Several CNAs reported choosing sling sizes based on the resident’s body type or guessing, and one CNA stated she relied on training from previous employers. Staff were generally unaware of which sling to use for specific residents and could not readily locate up-to-date written resources; binders that were supposed to contain lift and sling information were missing or outdated. A paper list of sling sizes found in a communication binder was acknowledged by an RN as not updated. Another RN stated she did not know residents’ sling sizes and would ask a CNA for guidance. Record review confirmed that not all direct care staff, including CNAs involved in the incidents, had completed required competencies on total body lifts or sit-to-stand lifts after the reported incident, despite having worked shifts since that time. Further review of resident records showed that for several residents who used mechanical lifts, care plans and Kardexes lacked documentation of sling size and, in some cases, did not even specify the type of lift to be used. For example, one resident’s care plan and Kardex indicated a need for two-person assistance with transfers but did not identify any transfer equipment. Surveyors also compared an updated list of transfer equipment to slings stored in residents’ rooms and found discrepancies between listed sling sizes and those actually present or documented in the Kardex for certain residents. The facility’s own sling sizing chart and manufacturer’s instructions for the EZ Way Smart Lift outlined proper sling positioning and sizing parameters, including that the base of the sling should be positioned two inches below the tailbone and the top parallel with the shoulder line, but observed practice and staff statements demonstrated that these guidelines were not consistently followed.
Resident Left Unattended on Toilet Resulting in Potential Neglect
Penalty
Summary
The deficiency involves a resident being left unattended on a toilet in the beauty shop bathroom for an extended period, despite requiring staff assistance and supervision. The resident was later found by the charge nurse sitting on the toilet with the sit-to-stand lift still attached, the bathroom door closed, and the call light not activated. Prior to this, a CNA had noticed the resident’s room call light on, but the resident was not in his room; the CNA turned off the call light and proceeded to answer other call lights without locating the resident. The facility’s investigation identified that a certified medication aide (CMA) had taken the resident to the beauty shop bathroom earlier in the afternoon but did not inform other staff or acknowledge doing so, even though witnesses reported seeing the CMA escort the resident to that bathroom. The resident’s medical record showed moderately impaired cognition with a BIMS score of 8, diagnoses including Parkinson’s disease, unspecified dementia, hallucinations, and sensorineural hearing loss, and a high fall risk with a Morse fall scale score of 75. The care plan documented the need for a sit-to-stand lift for transfers, maximal/substantial assistance for toileting, and dependence on staff for toileting hygiene, as well as a focus on risk for pressure ulcer development related to immobility and incontinence. A Braden scale score of 13 indicated moderate risk for pressure ulcers. After being left on the toilet for an unknown but extended time, the resident was assessed by the charge nurse and found to have slight redness on the buttocks consistent with prolonged sitting on the toilet seat; the redness resolved before the end of the shift. There was no documented pain assessment or skin assessment in the medical record following this incident. Staff interviews revealed inconsistent practices and lack of clear guidance regarding monitoring residents left on toilets. One CNA reported checking assigned residents every two hours and returning to the bathroom within five to ten minutes if a resident did not use the call light, noting that longer periods on the toilet could cause redness from pressure. Another CNA stated that some resident bathrooms were too small for lift equipment, so residents were taken to the beauty shop bathroom, but there was no specific process or policy on when staff should return to assist residents off the toilet; she relied on remembering to go back. During observation, a staff member transferred a resident into the beauty shop and closed the door without changing the door sign from “Vacant” to “Occupied.” The facility’s neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and outlined procedures for investigation and protection of residents, but there was no documentation that audits were conducted to ensure staff understood and implemented resident safety interventions related to this incident.
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