Rolling Hills Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Belle Fourche, South Dakota.
- Location
- 2200 13th Ave, Belle Fourche, South Dakota 57717
- CMS Provider Number
- 435035
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Rolling Hills Healthcare during CMS and state inspections, most recent first.
A resident identified as at risk for burns from hot liquids was served excessively hot coffee in a lidded Thermos without a clothing protector, contrary to her care plan. The coffee, sourced from an unmonitored employee breakroom, caused the resident to sustain burns when she expelled it onto her chest. Staff did not consistently follow required interventions, and the kitchen lacked a system to ensure residents received appropriate accommodations for hot beverages.
A resident with PTSD, developmental disabilities, and a history of childhood abuse did not receive comprehensive trauma-informed care. Staff failed to identify and address the resident's trauma history and mental health needs in her care plan, and did not obtain relevant psychiatric or therapeutic information. The lack of a trauma-informed approach contributed to an incident where the resident was burned by hot coffee, triggering distress and thoughts of self-harm.
A resident did not have access to a physician-ordered PRN Diazepam nasal spray for prolonged seizures because the medication was not available in the medication cart due to incomplete pre-authorization paperwork. Additionally, the resident's PRN Ativan order was changed to exclude seizure disorder as an indication, and the new order was incorrectly transcribed in the EMR, leaving the resident without an appropriate PRN medication for seizure management.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A registered nurse (RN) physically abused a resident during evening care by slapping her after the resident hit the RN. The resident, who had conditions such as hemiplegia and dementia, was forcefully handled by the RN despite her refusal to go to bed. The incident was witnessed by two CNAs, who reported feeling uncomfortable and were instructed by the RN not to report the incident. The RN was terminated, and the incident was reported to the South Dakota Board of Nursing and local law enforcement.
A facility failed to identify, assess, document, and notify a physician about a resident's pressure injuries. Despite reports from CNAs about sores on the resident's body, the DON and nursing staff were unaware of the current pressure injuries, and no documentation or physician notification was completed. The facility's policies for pressure injury management were not followed.
The facility failed to maintain proper food temperatures and timely delivery of meal trays to residents' rooms. A resident experienced delays in receiving meals, which were often cold and not as per his preferences. The steam table was left uncovered, and the plate warmer was malfunctioning, contributing to the issue. Additionally, a request for an alternative meal was delayed, highlighting a lack of coordination between dietary and nursing staff.
The facility failed to maintain resident dignity by not providing adequate assistance with bathing, clothing changes, and meal assistance. Several residents did not receive their preferred weekly baths, and staff were observed standing over residents during meals, contrary to policy. Additionally, two residents were observed with exposed stomachs due to improperly fitting clothing, and staff did not assist them in maintaining their dignity.
The facility failed to ensure proper labeling, dating, and covering of food items in the Bistro refrigerator/freezer and the walk-in refrigerator. Observations revealed undated and unlabeled food items, some past their best by dates, and uncovered items, contrary to the facility's policy. The dietary manager noted that removing outdated food items was recently added to the staff's cleaning checklist.
The facility failed to maintain a clean and homelike environment, with strong urine odors and unclean conditions observed in public areas and resident rooms. A resident's room was cluttered with medical supplies and personal items, remaining unclean over several days. Interviews revealed dissatisfaction with the facility's upkeep, despite cleaning procedures and staff advocacy efforts.
A resident experienced an unresponsive episode and was later found to have an acute, displaced oblique fracture in the left leg. Despite complaints of pain and the fracture diagnosis, the facility did not investigate the cause of the injury or report it to any outside agency, violating their policy on reporting and investigating injuries of unknown origin.
The facility failed to ensure care plans for several residents were followed and updated. A resident with a compromised immune system did not have proper contact precautions followed, and another resident's care plan did not reflect the use of necessary Velcro straps for wheelchair safety. Additionally, a resident's care plan lacked information on seat belt use, and another resident's bed height was not properly marked, leading to inconsistencies in care delivery.
The facility failed to ensure proper physician orders for oxygen use for two residents, and therapeutic boots were not provided as ordered for another resident. Meal documentation was inaccurate for a resident with significant weight loss, and a resident using Velcro straps was not assessed for restraint use. Additionally, a resident self-administering medication lacked a complete evaluation of allowed medications.
The facility failed to maintain required water temperatures in the kitchen's three-compartment sink, increasing the risk of foodborne illnesses. Observations showed wash water temperatures were consistently below the required 110°F, and sanitizer water temperatures were not maintained at 75°F. Staff interviews revealed a lack of awareness of the correct temperature requirements, and log reviews showed discrepancies in recorded temperatures and PPMs.
The dietary supervisor, who also worked part-time as the HR director, had not completed the necessary dietary manager training or ServSafe certification. Additionally, she was unaware of relevant state and federal regulations. A registered dietician consulted at the facility but not full-time. The job description required certification as a dietary manager within four months and maintaining ServSafe certification.
A cook in an LTC facility failed to maintain proper infection control practices during meal service. Observations revealed the cook used the same gloves for multiple tasks, including handling food and kitchen items, without changing them, increasing the risk of cross-contamination. Additionally, a damaged food processor cover was used, further compromising food safety. The facility's policy on glove use was not followed, as confirmed by the dietary supervisor.
A resident fell from a tub chair because the lap belt, meant to secure them, was not properly placed. The resident was assessed and transferred to the ER, where no fractures were found, but low blood pressure was noted.
A resident with dementia and a history of wandering successfully eloped from the facility by disabling door alarms and walking two blocks away. Despite previous exit-seeking behaviors, the resident was assessed as low risk for elopement. The facility's interventions, including staff education and supervision, were not effectively implemented, leading to the deficiency.
Failure to Implement Hot Liquid Safety Interventions Results in Resident Burn
Penalty
Summary
Staff failed to implement required safety interventions for a resident identified as being at risk for burns from hot liquids. The resident's care plan and Hot Liquid Safety Evaluation specified the need for a cup with a lid and a clothing or lap protector when consuming hot beverages. Despite these documented interventions, the resident was served hot coffee in her personal Thermos cup without verification of the coffee's temperature, and she was not provided with a clothing protector at the time. The coffee, obtained from the employee breakroom where temperatures were not monitored, was too hot, resulting in the resident expelling it onto her chest and sustaining small blisters. Further review and interviews revealed that the kitchen did not maintain a list of residents requiring specific accommodations for hot beverages, and there were no lidded mugs available for general resident use. The resident sometimes used unlidded mugs from the kitchen, contrary to her care plan. Staff, including the CNA and kitchen staff, were unaware of the temperature differences between coffee sources and did not consistently follow the interventions outlined in the resident's care plan to mitigate the risk of burns from hot liquids.
Failure to Implement Comprehensive Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement comprehensive trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), developmental disabilities, anxiety, major depressive disorder, and a seizure disorder. The resident, who had a history of childhood abuse, experienced a triggering event when a certified nurse aide provided her with hot coffee, resulting in a burn to her chest. This incident caused the resident to recall past trauma and led to thoughts of self-harm, necessitating her transfer to a hospital for evaluation. Prior to this incident, the resident's trauma history and mental health needs were not adequately identified or addressed in her care plan. Trauma assessments conducted after admission did not capture her trauma history, developmental and functional background, support network, or coping mechanisms. The social services designee acknowledged that she had limited information about the resident's trauma and had not proactively sought additional psychiatric or therapeutic records, nor had she requested the resident's individual service plan from her previous community-based program. The facility's policy required a multi-pronged approach to identifying trauma history and collaboration with relevant professionals to develop individualized care plans. However, these steps were not followed, and a trauma-informed care plan was not initiated until after the burn incident. The social services designee also did not follow up with the resident's counselor regarding recommended anxiety management exercises, missing opportunities to integrate effective interventions into the resident's care.
Failure to Provide Ordered PRN Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication needs were met by not having a physician-ordered PRN Diazepam nasal spray available for administration in the event of prolonged seizure activity. The medication was not present in the medication cart when needed because the pharmacy was waiting for the resident's medical provider to complete and return pre-authorization paperwork. Despite the order being active in the resident's electronic medical record, the medication was never received by the facility. Additionally, the resident's PRN Ativan order, which previously included seizure disorder as an indication, was discontinued and replaced with an order for anxiety only, leaving the resident without an appropriate PRN medication for seizures. Interviews with staff confirmed that the PRN Diazepam nasal spray was not available and that the Ativan order was incorrectly transcribed, omitting seizure disorder as an indication. The Director of Nursing acknowledged that since the change in the Ativan order, the resident had no medication available to treat a prolonged seizure. The facility's policies required timely acquisition and clarification of medication orders, but these were not followed, resulting in the resident being left without necessary seizure medication.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
RN Slaps Resident During Evening Care
Penalty
Summary
The deficiency involved a registered nurse (RN) who physically abused a resident during evening care. The incident occurred when the RN slapped the resident while providing care, as reported by a certified nursing assistant (CNA) who witnessed the event. The resident, who had a history of hemiplegia, dementia, and moderate cognitive impairment, was subjected to forceful handling by the RN, which led to the resident hitting the RN, prompting the RN to retaliate by slapping the resident. The resident's medical record indicated she had existing conditions such as hemiplegia, dementia, and moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 8. Observations noted bruising and scratches on the resident, which were documented in skin assessments following the incident. The resident's care plan was updated to monitor for changes in mental state and behavior, although no new behaviors or fear were observed in the resident following the incident. Interviews with the CNAs present during the incident revealed that the RN was agitated and forceful, disregarding the resident's refusal to go to bed. The CNAs reported feeling uncomfortable with the RN's actions and were instructed by the RN not to report the incident. Despite the RN's actions, the resident did not exhibit any new behaviors or fear in subsequent interactions with the CNAs. The RN was terminated following the incident, and the matter was reported to the South Dakota Board of Nursing and local law enforcement.
Failure to Identify and Document Pressure Injuries
Penalty
Summary
The facility failed to properly identify, assess, document, and notify the physician regarding a resident's pressure injuries. Interviews with the Director of Nursing (DON), Certified Nursing Assistants (CNAs), and Registered Nurses (RNs) revealed inconsistencies in the awareness and documentation of the resident's pressure injuries. The DON initially stated that the resident's Stage III pressure ulcer had healed, but CNAs reported sores on the resident's buttock, inner thigh, and heels. Despite these reports, the DON and other nursing staff were not aware of the current pressure injuries, and no documentation or physician notification had been completed. The resident's electronic medical record indicated previous pressure injuries on the heels, which were noted to have healed. However, new observations revealed an open area on the resident's upper leg and a suspected deep tissue pressure injury on the heel. The Assistant Director of Nursing (ADON) and other nursing staff confirmed they were not previously aware of these issues. The facility's policies required thorough assessment, documentation, and physician notification for pressure injuries, which were not followed in this case.
Deficiency in Food Service Delivery and Temperature Maintenance
Penalty
Summary
The deficiency report highlights several issues related to the food service delivery at the facility, particularly concerning the temperature and timeliness of meal trays delivered to residents' rooms. During an observation of the evening meal service, it was noted that food was plated in a sequence that resulted in late trays being served at unappetizing temperatures. The steam table used to keep food warm was left uncovered, and the temperature was lowered to prevent gravy from burning, which affected the overall temperature of the food. Additionally, the plate warmer was not functioning properly, contributing to the cold food complaints from residents. Resident 43, who preferred to eat in his room due to a pressure ulcer, experienced significant delays in receiving his meals. On one occasion, his meal was delivered over forty-five minutes past the normal delivery time, and the food was cold upon arrival. Despite his requests for specific meal preferences, he often did not receive what he ordered, leading to dissatisfaction and refusal to fill out meal preference sheets. His request for an alternative meal of chicken noodle soup was also delayed, and when it was finally delivered, it was not hot enough for his liking. The facility's policies on food temperatures and in-room dining were not adhered to, as evidenced by the failure to maintain hot food at the required temperature of at least 135 degrees Fahrenheit. The nursing staff did not promptly serve meals upon arrival on the unit, and there was a lack of communication and coordination between the dietary and nursing staff, resulting in delayed and unsatisfactory meal service for residents like Resident 43.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The provider failed to ensure that residents maintained a sense of dignity by not providing adequate assistance with bathing, clothing changes, and meal assistance. Three residents did not receive their preferred weekly baths, as documented in their care plans. Interviews with CNAs revealed inconsistencies in the bathing schedule and documentation, with some residents refusing baths without proper follow-up. The facility's policy did not specify the frequency of baths, leading to gaps in care. One resident was observed with soiled clothing and food residue on her face and teeth after a meal, and staff did not address her appearance promptly. This lack of attention to personal hygiene and appearance compromised the resident's dignity. Additionally, during meal services, staff were observed standing over residents while assisting them with eating, contrary to the facility's policy that required staff to sit next to residents to provide a more dignified dining experience. Furthermore, two residents were observed in the dining room with exposed stomachs due to improperly fitting clothing. Staff failed to assist these residents in adjusting their clothing to maintain their dignity. The facility's dignity policy emphasized the importance of caring for residents in a manner that promotes their well-being and self-esteem, but these observations indicated a failure to uphold these standards.
Improper Food Labeling and Storage in Facility Refrigerators
Penalty
Summary
The provider failed to ensure that food items in the Bistro refrigerator/freezer and the walk-in refrigerator in the kitchen were properly labeled, dated, and covered. During an observation in the Bistro kitchenette, several food items were found without proper labeling or dating, including two pieces of pizza, multiple pieces of sliced pepperoni, half of a chocolate cream pie, a piece of cherry pie, and two ham sandwiches. Additionally, some items were past their best by dates, such as a container of Yoplait peach yogurt and a carton of vanilla ice cream. In the freezer, a Lean Cuisine dinner and an uncovered Dairy Queen Blizzard cup were also noted. Similarly, the walk-in refrigerator contained undated sandwiches and a container labeled with a date that was not compliant with the facility's policy. The dietary manager confirmed that the task of removing outdated food items was recently added to the kitchen staff's weekly cleaning checklist. The facility's policy requires all food items to be properly covered, dated, and labeled before being placed in any refrigerator or freezer. The 2019 Food and Nutrition Services in Healthcare Policy and Procedure Manual specifies that leftovers must be dated, labeled, covered, cooled, and stored in a refrigerator, which was not adhered to in this instance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by observations of strong urine odors and unclean conditions in both public areas and resident rooms. Specifically, the 300 wing's public area had lounge chairs with urine odor and stained carpets. Resident rooms, particularly those of residents 12 and 18, were found to be in disarray, with strong urine odors, clutter, and unclean surfaces. Resident 18's room contained various items scattered on the floor, including medical supplies and personal belongings, and was observed in the same condition over multiple days. Interviews with staff and family members highlighted ongoing concerns about cleanliness and maintenance. Resident 12's daughter expressed dissatisfaction with the facility's upkeep, noting persistent urine odors and inadequate room conditions. The facility's cleaning procedures, as described by a housekeeper, included daily tasks such as trash removal and surface cleaning, but did not address dusting if residents were present. Despite having a system where staff members acted as advocates to review room cleanliness and address resident concerns, the issues persisted, indicating a failure to ensure a clean and homelike environment.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The provider failed to investigate an injury of unknown origin for a resident who was sent to the emergency department due to an unresponsive episode. Upon returning to the facility, the resident was transferred using a sit-to-stand lift, during which the resident's daughter noticed instability in the resident's left leg. Despite complaints of pain and a subsequent X-ray revealing an acute, displaced oblique fracture, the facility did not investigate the cause of the injury. The director of nursing was aware of the resident's pain and had notified the primary care provider and family, but did not reach out to the emergency department for further information or report the fracture to any outside agency. The facility's policy requires all reports of resident abuse, including injuries of unknown origin, to be reported and thoroughly investigated. However, there was no documentation to support that an investigation was completed for the resident's fracture. The director of nursing confirmed that no investigation was conducted and that the fracture was not reported to the South Dakota Department of Health. The resident had a history of pathological fractures, but the lack of investigation and reporting was a violation of the facility's policy.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The provider failed to ensure that care plans for five of eight sampled residents were followed, updated, and revised promptly to reflect their current status and care needs. For Resident 18, there was a lack of adherence to contact precautions as the CNA was unaware of the specific precautions required, despite the resident having a compromised immune system and a history of ESBL in urine. Additionally, the care plan for Resident 18 included the use of an AFO for transfers and ambulation, which was not being utilized as the resident was dependent on a sit-to-stand lift and did not ambulate. Resident 29's care plan did not reflect the use of a Velcro strap for his left foot, which was necessary to prevent it from sliding off the wheelchair pedal. The resident was paralyzed on the left side and required assistance with the placement of Velcro straps on his hand and foot. Similarly, Resident 26's care plan did not include information regarding the use of a seat belt on his wheelchair, despite a physician's order for its use. The resident was able to remove the seat belt himself, but staff members continued to place and latch it around him. Resident 46's care plan included the use of a full-body mechanical lift for transfers, but the interventions for his risk of falls and injuries were not adequately addressed. The care plan for Resident 6 included a specific bed height marked by blue tape, which was missing from the wall, leading to staff estimating the bed height. The interdisciplinary team was responsible for updating care plans, but there was a failure to ensure that care plans were revised as residents' conditions changed, leading to inconsistencies in care delivery.
Deficiencies in Oxygen Orders, Therapeutic Boots, and Documentation
Penalty
Summary
The facility failed to ensure that two residents using oxygen concentrators had the necessary physician orders for oxygen administration. Observations revealed that an oxygen concentrator was present in the room of one resident, who had been using it since returning from the emergency department, yet there was no physician order or care plan documentation for its use. The Director of Nursing confirmed the absence of an order and was unaware of the resident's oxygen use, noting that the concentrator was intended for another resident, who also lacked an order for oxygen. Another deficiency involved a resident who was supposed to use therapeutic boots as per physician orders. Observations showed that the only brace found in the resident's room was an AFO, not the prescribed Multipodus or Thera-boots. Interviews with staff, including the Director of Nursing and the Director of Rehab, confirmed the absence of the required boots and highlighted a misunderstanding regarding the types of braces ordered. The resident's care plan did not reflect the physician's orders for the therapeutic boots. Additional issues included inaccurate meal documentation for a resident who had significant weight loss and required assistance with meal setup. The documentation inaccurately reflected meal consumption, as the CNA responsible for the documentation had not observed the meal intake. Furthermore, a resident using Velcro straps for stabilization had not been assessed for restraint use, contrary to the facility's policy. Lastly, a resident self-administering medication did not have a complete evaluation listing the medications he was allowed to self-administer, as required by the facility's procedures.
Failure to Maintain Proper Water Temperatures in Kitchen
Penalty
Summary
The provider failed to maintain the required water temperatures in the three-compartment sink in the kitchen, which increased the potential risk of foodborne illnesses for the residents. Observations revealed that the wash water temperature was consistently documented as 90 degrees Fahrenheit or lower, contrary to the required 110 degrees Fahrenheit. Additionally, the sanitizer water temperature was not maintained at the required 75 degrees Fahrenheit. Interviews with kitchen staff, including a cook and the dietary supervisor, indicated a lack of awareness and understanding of the correct temperature requirements. The dietary supervisor admitted to not knowing the expected wash water temperature and only reviewed logs to ensure documentation was completed, not to verify if the data was within expected parameters. A review of the August 2024 Three-Compartment Sink Log showed discrepancies, with wash water temperatures either exceedingly high or low, and no wash water temperatures documented for the entire month. The sanitizer water temperature was often recorded in the wrong column, and many recorded PPMs were below the expected range. The deficiency was identified as an immediate jeopardy situation, requiring immediate corrective action. The provider's failure to adhere to the Food and Drug Administration's recommendations and their own policy for maintaining proper water temperatures in the kitchen's three-compartment sink posed a significant risk to the health and safety of the residents receiving meals prepared in the facility.
Removal Plan
- DM educated all dietary staff on the 3 sink method, 3 compartment sink order, 3 compartment sink steps, water temperature in a 3 compartment sink, sanitizer temp, and when it is essential to clean and sanitize a utensil, sanitizer per manufacturer recommendations that include submerging for at least 1 minute.
- Education to dietary staff on compartment sink log requirements of testing temps and sanitizer ppm, including action required if temps are not within the requirements.
- DM, primary dayshift cook, primary evening cook, are enrolled in ServSafe Certification.
- All new dietary staff will receive ServSafe certification.
- A new log was created by DM to record wash, rinse, sanitizer water temperatures, and sanitizer ppm with each use, including what to do if temps or ppm are outside of parameters.
- LNHA provided education to DM on the policy and procedure manual, including 3 compartment sink method regulations, job description of the dietary manager including adherence to policies and ensure that sanitary regulations are followed by the entire department.
- Education provided on supervisory roles including ensuring the department adheres to State and Federal regulations, and assuming the authority, responsibility and accountability to carry out the duties of the dietary department, monitor use of equipment and chemicals, and ensuring required documentation is completed and appropriate per regulations.
- Education included reporting to LNHA any areas of concern within the dietary department, equipment, and chemicals.
- Dietary manager will complete ServSafe certification.
Dietary Supervisor Lacks Required Training and Certification
Penalty
Summary
The provider failed to ensure that the dietary supervisor met the necessary requirements to manage the food and nutrition services effectively. The dietary supervisor, who assumed the position on a part-time basis in February 2024, was also working part-time as the human resources director. At the time of the interview, the dietary supervisor had not completed the required dietary manager training program and was not aware of the state and federal regulations related to her position. Additionally, the dietary supervisor had not completed the required ServSafe training program. Although a registered dietician consulted at the facility, it was not on a full-time basis. The job description for the dietary supervisor position required certification as a dietary manager or a commitment to become certified within four months of employment, as well as maintaining current ServSafe certification.
Infection Control Breach During Meal Service
Penalty
Summary
The provider failed to maintain proper infection control and prevention practices during a meal service, as observed with one cook, identified as cook C. During the preparation of the noon meal, cook C was seen using gloved hands to cover metal containers with aluminum foil, then reaching into her pocket to retrieve a permanent marker, which she used to write on the foil before returning it to her pocket. She continued to use the same gloves to handle various kitchen items, including oven mitts, pans, cabinet doors, drawer handles, and meal service utensils, without changing gloves. Cook C eventually removed the gloves, citing sweaty hands, and performed hand hygiene before donning a new pair of gloves. Further observations revealed that cook C used a damaged food processor cover, which was cracked and missing a piece of plastic, to puree pasta. After use, she washed the cover in a three-compartment sink and left it to dry. Additionally, while plating food items, cook C used the same gloves to touch the food service cart, retrieve clean cups, operate the microwave, and handle food items without changing gloves between tasks. The dietary supervisor confirmed that gloves were not used properly, increasing the risk of cross-contamination. The facility's policy on glove use emphasized the need for glove changes to prevent contamination, which was not adhered to in this instance.
Resident Safety Compromised Due to Improper Use of Tub Chair Belt
Penalty
Summary
The provider failed to ensure the safety of a resident who fell from a tub chair due to the improper placement of a lap belt intended to secure the resident. The incident occurred when the lap belt was not placed around the resident, leading to the fall. Following the fall, the resident was assessed at the facility and found to have no apparent injuries. However, the resident was transferred to the emergency room for further evaluation, where X-rays showed no bone fractures, but low blood pressure was identified.
Failure to Accurately Assess Elopement Risk
Penalty
Summary
The provider failed to ensure an accurate assessment of elopement risk for a resident who successfully eloped from the facility. The resident, who had a diagnosis of dementia with agitation and anxiety, was able to enter the code to turn off the alarms on the door to the enclosed patio and courtyard, exit the courtyard, and walk approximately two blocks from the facility before being found. The resident's medical records indicated a SLUMS score suggesting possible dementia and a Brief Interview of Mental Status score indicating intact cognition. However, the resident's Elopement Risk Assessment conducted on 6/14/24 classified him as low risk for elopement, despite previous behaviors of wandering and exit-seeking. The resident's care plan included interventions for his wandering and exit-seeking behaviors, such as staff education, 1:1 visits, and constant supervision. However, these interventions were not effectively implemented, as evidenced by the resident's ability to elope. Interviews with staff revealed that the resident often wandered and had a history of going outside without informing anyone. Despite these behaviors, the staff did not consider the resident at risk for elopement until after the incident on 6/24/24. The facility's policies on wandering and elopements and resident assessments were reviewed, indicating that the facility aimed to identify residents at risk for unsafe wandering and involve all care team members in the assessment process. However, the facility's failure to accurately assess and address the resident's elopement risk led to the deficiency. Interviews with the facility's administration and staff highlighted a lack of recognition of the resident's elopement risk and insufficient monitoring and intervention to prevent the elopement.
Latest citations in South Dakota
Two residents experienced failures in timely implementation of physician orders and provider notification. One resident with cognitive impairment, respiratory failure, pneumonia, and a urinary catheter had a UA/UC ordered after increased confusion, but catheter change and urine collection were delayed and inconsistent, and an antibiotic order faxed for a UTI was left on a reception fax machine and never started before a later order changed therapy based on culture results. Lab reports showing Enterobacter cloacae and susceptibility to a different antibiotic were not consistently documented as reviewed, and the resident continued to exhibit confusion and flank pain until transfer to the ER. Another resident with ESRD on dialysis, hypotension, hypertension, and heart failure had orders for Midodrine with BP parameters and daily Metoprolol, but Midodrine was not given on dialysis mornings and Metoprolol was rarely given on dialysis days, without notifying the physician. Very low BPs were recorded without documented provider notification or repeat checks, despite a TAR requiring monitoring for post-dialysis complications. Interviews and policy review showed expectations to follow orders and notify physicians of abnormal labs, omitted medications, and changes in condition, which were not met in these cases.
Two residents at high risk for pressure ulcers did not receive consistent, individualized prevention and treatment measures, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment and high Braden risk, fully dependent on staff for mobility and hygiene, was repeatedly observed in bed with the head of bed elevated and sliding down, without documented q2h repositioning, individualized pressure-relief interventions, or consistent use of barrier cream, and CNAs and restorative staff were unaware of specific pressure-prevention measures for her. Another resident with multiple comorbidities, prior healed pressure ulcers, and a high Braden score developed recurrent stage II and III pressure ulcers to the coccyx and gluteal fold, a left heel DTI, and a left lateral leg stage II ulcer; ordered wound treatments were not documented as completed on at least one ordered date, he was not on a defined turning schedule despite being largely bedfast, and heel offloading and use of heel boots were inconsistently implemented and documented. In both cases, staff interviews and record review showed that facility practices did not consistently align with the facility’s own skin and pressure injury prevention policy requiring q2h repositioning, appropriate support surfaces, and systematic offloading for bedfast residents.
The deficiency centers on unsafe resident transfers and unsecured chemicals. A resident with hemiplegia and severe cognitive impairment, care planned for a one-person sit-to-stand (STS) lift transfer, was instead manually transferred by a CNA without the lift, during which the resident’s legs gave out, he was lowered to the floor, hit his head, and later was found to have a subdural hematoma. Another resident with severe cognitive impairment and documented inability to meet STS criteria was nonetheless assessed and care planned for STS transfers, while staff and family intermittently pivot transferred her without a gait belt and with inconsistent use of mechanical lifts, amid reports that pocket care plans and Kardex information were not kept up to date. Additionally, surveyors repeatedly observed an open tub room with unlabeled and labeled chemical spray bottles accessible on the tub, and an unattended housekeeping cart in the dining room with toilet bowl cleaner and other disinfectants unlocked and reachable by residents, contrary to staff statements that such rooms and chemicals were to be secured.
The facility failed to consistently honor resident preferences and care‑planned frequency for bathing, resulting in multiple residents going six to ten days or longer between baths despite being scheduled for twice‑weekly showers or baths. Several residents, including those with impaired and intact cognition, reported missed or inconsistent baths, needing to repeatedly remind CNAs, and being told they were skipped due to other residents waiting longer, staffing shortages, or equipment issues. Observations included a resident with long, jagged fingernails and urine odor who reported missed scheduled showers. Review of EMRs and the bath schedule showed numerous missed baths without documented refusals or valid reasons, while the grievance log and resident council minutes documented ongoing complaints from multiple residents about not receiving baths as scheduled. Nursing staff acknowledged receiving complaints and that residents sometimes went more than a week without bathing, despite a facility policy stating residents have the right to choose timing and frequency of bathing and requiring documentation of bathing activity or refusals.
Two cognitively intact residents with significant ROM and mobility limitations did not receive their care-planned restorative nursing programs as ordered. One resident with DM, neuropathy, above-knee amputation, and CKD reported increasing stiffness and weakness and stated that staff no longer brought her for exercises; records showed only sporadic lower extremity and kinetic bike sessions over several months despite physician orders and a care plan for regular AROM and restorative activities. Another resident with RA, polyneuropathy, and prior fractures, who used a power wheelchair, reported not receiving her prescribed exercise program and feeling she was losing strength; her MDS and restorative documentation showed no completed restorative exercises or standing with a walker despite a detailed restorative care plan. Therapy staff and RAs confirmed written restorative recommendations and expectations for 3–6 sessions per week, but reported that two RAs were responsible for about 44 residents, could not see all residents daily, prioritized those more willing or independent, and were unsure when these two residents last received restorative exercises, while the DON acknowledged awareness of staffing difficulties and confirmed the minimal restorative services actually provided.
Staff failed to maintain dignity, hygiene, and privacy for multiple dependent residents. A resident with severe cognitive impairment and depression was left in bed in nightclothes with dried food and juice on her body and linens, and was observed with a dried substance on her nose that was not cleaned over time, despite her reliance on staff for all personal care. Another cognitively impaired resident, dependent on staff for hygiene and dressing, was repeatedly observed wearing a heavily soiled shirt, with food in his beard and thick residue on his fingers, and continued to spill coffee on himself in the dining room without staff assistance or interventions; there was no documentation that he refused care. A third cognitively impaired resident with severe mental illness and risk for abuse and neglect was provided incontinence care while standing at the sink in a shared room without adequate use of the privacy curtain or window blinds, allowing his roommate and potentially others to see him during intimate care, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment, dementia, metabolic encephalopathy, a history of stage II pressure ulcers, and a urinary catheter was left in a dining room for about ten hours without receiving care as outlined in the care plan. The resident’s plan required repositioning every two hours, substantial assistance with toileting hygiene every two to three hours, monitoring of urine output each shift, and extensive assistance with transfers and wheelchair mobility. On the day of the incident, the resident was brought to the dining room in the morning and not returned to his room until evening, and the assigned CNA and LPN did not provide the scheduled care during this time. The facility’s investigation determined that this failure to follow the care plan and provide necessary care for an extended period constituted neglect.
A resident with a history of making allegations of rough care and a care plan requiring all care to be provided by two caregivers was assisted by a single CNA, contrary to the documented "cares in pairs" intervention. The care plan identified manipulative behavior and alleged mistreatment, and specified that two caregivers should be present to address the resident’s needs and observe the entire care session. On one occasion, the CNA entered the room alone and began providing care, after which the resident reported to an LPN that the CNA had been rough, leading to a deficiency citation for failure to follow the resident’s care plan under F684.
Two residents who required two-person assistance with mechanical lifts were subjected to unsafe transfers when CNAs used improperly sized, mispositioned, or incompatible full-body slings and did not follow manufacturer instructions. In one case, a resident newly admitted with a hospital-provided sling was lowered to the floor during a lift transfer after sliding forward in the sling, resulting in reported rib pain but no fractures on X-ray. In another case, a resident’s wheelchair pad and handle became entangled in a large sling during a lift, causing the wheelchair and resident to be lifted off the floor; the sling remained incorrectly positioned at mid-back when the resident was lifted again and moved to bed. Multiple CNAs and nurses reported no recent facility-specific training or competencies on mechanical or sit-to-stand lifts, selected sling sizes by guessing based on body type or using whatever sling was in the room, and lacked clear, updated care plan or Kardex documentation specifying lift type and sling size for residents who required mechanical lifts.
A resident with moderately impaired cognition, Parkinson’s disease, dementia, high fall risk, and moderate pressure-ulcer risk, who required a sit-to-stand lift and maximal assistance for toileting and hygiene, was taken to a beauty shop bathroom by a CMA and left unattended with the lift attached, the door closed, and no call light activated. The resident was later found by a nurse after an extended, unknown period and had transient redness on the buttocks consistent with prolonged sitting. Documentation lacked a post-incident pain and skin assessment. Staff interviews showed there was no clear, consistent process for how often CNAs should check on residents left on toilets, and an observation revealed a staff member failed to change the beauty shop door sign to indicate occupancy, all occurring under a facility neglect policy that defines neglect as failure to provide necessary goods and services to avoid harm.
Failure to Follow Physician Orders and Notify Providers for Infection Management and Dialysis-Related Care
Penalty
Summary
The deficiency involves failures to follow physician orders in a timely manner and to notify providers of significant clinical information for two residents. For one resident with moderate cognitive impairment, respiratory failure, pneumonia, and an indwelling urinary catheter, the physician ordered a UA/UC after the resident’s son reported increased confusion and requested urine testing. The order for catheter change and urine collection was received and noted, but the catheter change documented on the treatment record as due on one date was not completed until early the next morning. Lab reports show urine samples collected on two different dates and times, with one sample having been collected and then recollected. The resident’s son reported being told that a urine sample had sat in the refrigerator too long and had to be recollected, and that the facility did not start the initially ordered antibiotic while the culture was pending. The lab ultimately reported Enterobacter cloacae complex in high colony counts, and the physician ordered cefuroxime, then later discontinued it and ordered nitrofurantoin based on susceptibility results. The cefuroxime order, faxed on a Friday, was not implemented because it remained on a fax machine in the front reception area over the weekend and was not found until the following Tuesday, at the same time the later order to stop cefuroxime and start nitrofurantoin was found. The cefuroxime order was not noted as reviewed by staff, and the preliminary and final culture reports, including susceptibility results showing the organism was not susceptible to cefuroxime but was susceptible to nitrofurantoin, were not consistently documented as reviewed with clear dates and staff identifiers. Progress notes document ongoing confusion, flank pain, and the resident’s belief that there was urine in her oxygen tubing, as well as the son’s concerns and request for transfer to the emergency room. The DON later documented that her investigation found the 7/11 cefuroxime order had not been started because it was discovered only when the 7/15 order to stop it and start nitrofurantoin was located, and interviews revealed uncertainty about why the UA was recollected and that the incident investigation did not address the delayed UA collection or lack of on-call physician notification for preliminary lab results. For a second resident with intact cognition and diagnoses including ESRD on dialysis, hypotension, hypertension, and heart failure, physician orders directed dialysis three times weekly, Midodrine three times daily for hypotension with a parameter to hold if SBP was 120 or greater, and daily Metoprolol Succinate ER for hypertension without hold parameters. The March MAR shows the resident did not receive Midodrine on the mornings of dialysis days and received Metoprolol only once on a dialysis day during a specified period, with no documentation that the physician was notified of these omissions. Dialysis records show pre-dialysis BPs in the low-normal range, and the MAR documents very low BPs on one evening and the following morning, with no documentation that the provider was notified of these low readings. The TAR required monitoring for post-dialysis complications, including hypotension symptoms, twice daily on dialysis days, but only one day in the month reflected documented symptoms. Interviews with nursing staff and the DON confirmed expectations that physician orders be processed within the shift, that abnormal labs and out-of-parameter vitals be reported, and that Midodrine be given before dialysis when within parameters, but also revealed uncertainty about processing timelines, lack of a facility policy on vital sign parameters, and that the physician was not notified about the inconsistent administration of Midodrine and low blood pressures. Facility policies required following all physician orders and notifying the physician when orders were not followed or when there was a significant change in status, but these were not adhered to in these cases.
Failure to Implement Individualized Pressure Ulcer Prevention and Treatment for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and individualize pressure ulcer prevention and care for two residents at high risk for skin breakdown, resulting in the development and worsening of multiple pressure injuries. One resident with severe cognitive impairment, diabetes, depression, and high Braden risk was dependent on staff for hygiene, repositioning, and transfers. On admission, she had no skin breakdown but was identified as at risk. Her care plan initially addressed potential skin impairment but did not include individualized repositioning or pressure-relief interventions beyond standard admission practices. Staff and leadership later acknowledged that the pressure ulcer prevention measures in place before her ulcer developed were standard for all admissions and not tailored to her specific risk factors. For this resident, documentation showed blanchable redness to the buttocks on a skin assessment, followed by identification of a facility-acquired abrasion to the left buttock and coccyx and additional undescribed areas on the backs of both thighs. The next day, the abrasion on the left buttock was documented as a stage II pressure ulcer, which later increased in size. Observations on multiple days showed the resident lying in bed on her back with the head of the bed elevated and her body bent at the chest, with staff acknowledging that this positioning increased the risk of shearing when she slid down in bed. Interviews revealed that she could not turn herself in bed and required staff assistance for repositioning, yet there was no documentation that she was turned every two hours, and the DON could not find evidence that she refused repositioning or barrier cream. CNAs and a restorative aide reported not knowing what pressure prevention interventions were in place for her, and one CNA left her in bed all day because the resident did not respond when asked if she needed anything, despite the resident’s inability to use the call light or reposition herself. The second resident had multiple serious medical conditions, including spinal stenosis, chronic kidney disease, atherosclerotic heart disease, dysphagia, and protein-calorie malnutrition, and was assessed as high risk for pressure ulcers on the Braden scale. He had a history of multiple pressure ulcers and other wounds that had previously healed, but subsequent skin evaluations documented recurrent redness and pressure areas, including a right gluteal fold pressure ulcer and coccyx involvement. Progress notes identified a bleeding open area under the right buttock, reclassification of a right gluteal fold lesion from MASD to a pressure ulcer, and later documentation of a large coccyx pressure area, a left lateral heel DTI, and a left lateral lower leg stage II pressure blister. His care plan listed multiple active pressure injuries and interventions such as an air mattress, pressure-redistributing cushions, wound treatments, and weekly wound monitoring. Despite these identified wounds and orders, the record showed that ordered wound care treatments were not documented as completed on at least one ordered date, and the DON agreed that if treatments were not signed as completed, they were not done, and that wounds would worsen if treatments were missed. Interviews with nursing leadership and the wound nurse indicated that the resident was not on a formal repositioning schedule, even though standard practice was to reposition residents every two hours, and that his heels were offloaded and repositioned only “as needed.” Staff reported that he often refused to get up in his wheelchair and refused heel lift boots, but refusals and effective approaches were not consistently documented. A PA-C stated she would expect preventative measures such as an air mattress to prevent recurrence of pressure ulcers, and the DON and RN unit manager confirmed that an air mattress was ordered only after multiple pressure injuries were documented. The facility’s own Skin and Pressure Injury Prevention Program policy required offering repositioning at least every two hours for bedfast residents, considering off-loading when the head of bed was elevated, and using special mattresses as indicated, but the documented care and staff interviews showed gaps between these policy requirements and the actual implementation of pressure ulcer prevention and treatment for this resident. Overall, for both residents, surveyors identified failures to consistently implement and document individualized pressure ulcer prevention measures such as scheduled repositioning, appropriate use of pressure-relieving surfaces, barrier creams, and heel offloading, as well as failures to ensure staff understood and followed care plan interventions. These failures occurred despite both residents being clearly identified as high risk for pressure injury and, in the second case, having a documented history of prior pressure ulcers and multiple active wounds.
Unsafe Transfers and Unsecured Chemicals Leading to Resident Injury and Exposure Risk
Penalty
Summary
The deficiency involves failures to ensure safe transfers in accordance with resident care plans and to secure hazardous chemicals from resident access. One resident with hemiplegia following a stroke and severe cognitive impairment, who was care planned to transfer with one staff using a sit-to-stand lift, was transferred by a CNA without the lift from the toilet to a wheelchair. During this transfer, the resident’s legs gave out, he was lowered to the floor, and his head struck the wall, resulting in a skin tear on his left forearm, a bump on the back of his head, and elevated blood pressure and pulse. A CT scan later revealed a subdural hematoma. The DON reported that the CNA had been educated that same morning on the importance of following resident care plans, and the CNA stated she did not use the stand lift because she believed she could complete the transfer faster without it. A second resident with senile degeneration of the brain and severely impaired cognition was also not consistently transferred according to her assessed needs and care plan. Her care plan initially indicated use of a sit-to-stand lift, but a lift assessment documented that she could not bear at least 50% of her weight on one leg, could not sit upright without physical assistance, and could not follow simple instructions, which meant she did not meet the criteria for a sit-to-stand lift. Despite this, the assessment summary still indicated she was to use a sit-to-stand lift for bed-to-chair transfers, and she was care planned to use a sit-to-stand lift until later revised to a full-body mechanical lift. The resident’s family member reported concerns about transfers, including that staff did not use a gait belt, that she had assisted staff with pivot transfers, and that staff sometimes used a sit-to-stand lift and sometimes pivot transferred the resident with two staff. A CNA/CMA described pivot transferring this resident with the assistance of the family member by placing their arms under the resident’s arms and moving her from bed to a bath chair, during which the resident did not follow directions or move her feet, and the CNA/CMA held the resident up while quickly pulling the bath chair under her. Documentation and communication tools used by staff to determine transfer methods were not consistently accurate or up to date. Staff reported relying on the Kardex and pocket care plans to determine how residents should be transferred, and multiple staff acknowledged that pocket care plans were not always kept current. For the second resident, the pocket care plan at one point indicated she was a pivot transfer with one staff, while her family stated she required at least two staff for a pivot transfer and had previously used a mechanical lift in another facility. Later, the undated pocket care plan for her hallway indicated she was to be transferred with a full-body mechanical lift and sling. The DON and administrator confirmed that the initial lift assessment for this resident showed she was not a candidate for a sit-to-stand lift, yet she was care planned to use one. The deficiency also includes unsecured hazardous chemicals accessible to residents in a bathtub room and in the main dining area. On multiple observations, the blue hallway bathtub room door was open with no staff present, and a pink crate on top of the bathtub contained two spray bottles, one labeled Multi-Surface Peroxide cleaner with warnings that it causes skin irritation and serious eye damage, and another unlabeled bottle two-thirds full of an unknown liquid. Staff, including a CNA and RN, stated the bathtub room doors were supposed to be closed and locked to prevent resident access and exposure to unsecured chemicals, and the DON and regional nurse consultant confirmed the presence of the labeled and unlabeled chemicals and that the unlabeled bottle did not contain water. In the main dining room, an unattended housekeeping cart was observed with residents present and no staff nearby. The cart contained an open bottle of toilet bowl cleaner on an unlocked portion of the cart, and additional chemicals, including Multi-Surface Peroxide cleanser and Micro Kill foaming disinfectant cleaner, were stored in a lockable compartment that was left unlocked, with the keys on top of the cart. The administrator verified that the chemicals were not secured from resident access and that the bathtub room was supposed to be closed, locked, and accessible only by staff, and that chemicals were expected to be stored in their original labeled containers in a secure location.
Failure to Honor Resident Bathing Preferences and Scheduled Bathing Frequency
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor residents’ rights to choose and receive bathing at the frequency specified in their care plans and preferences. Multiple residents who preferred bathing at least twice weekly did not consistently receive baths or showers as scheduled, and staff did not consistently document refusals or reasons for missed baths. For one resident with severely impaired cognition, the care plan dated 3/25/26 indicated a preference for two baths per week, yet electronic records from 1/28/26 through 3/25/26 showed she received a bath on 3/9/26 and 3/16/26, refused on 3/13/26, was marked as “not available” on 3/20/26 without any supporting documentation that she was out of the facility, and had no documentation of being offered or receiving a bath on 3/23/26. A family member reported concerns that this resident had only received one shower since admission and raised these concerns to the administrator. Another resident with moderately impaired cognition had a care plan dated 3/25/26 indicating a preference for two baths per week. The bath schedule showed he was to receive baths or showers twice weekly on specific days, and there was no documentation of refusals. However, bathing records from 1/28/26 through 3/25/26 showed gaps of six and seven days between some baths, including a seven‑day interval before a bath on 2/21/26 and a six‑day interval before a bath on 3/13/26. This resident reported that there were times he did not receive a bath for a week, that he had to repeatedly remind staff to get a bath, and that the days he was bathed were inconsistent, sometimes occurring every other day and other times with a week between baths. A cognitively intact resident with a care plan preference for two baths per week was scheduled for baths on two specific days each week, but bathing documentation showed missed baths on multiple dates with no refusals recorded. As a result, there were intervals of seven and ten days between baths. This resident stated he did not receive the showers he was supposed to and was unsure if he would receive a scheduled shower on the day of interview. Another resident with moderately impaired cognition, whose care plan indicated a preference for two to three showers per week and who was scheduled for showers on Sundays and Thursdays, had multiple missed showers without documented refusals and repeated six‑day gaps between bathing. During observation and interview, this resident had long, jagged fingernails, smelled of urine, and reported that showers were sometimes not provided on scheduled days or were changed, and that staff had told him he would not get a shower because the shower was being repaired. The facility’s own bath schedule listed specific days for each of these residents to receive baths or showers, but documentation and resident interviews showed that these schedules were not consistently followed. The grievance log from November 2025 through March 2026 recorded multiple resident complaints and resident council concerns about not receiving baths or showers as expected, including reports from several residents that they had gone extended periods without bathing and that staff told them they were being skipped because other residents had waited longer or due to staffing issues. During a resident council interview, several residents reiterated that baths were not completed as scheduled and described waiting from eight days up to three weeks between baths, as well as equipment issues such as a broken chair that prevented bathing. Nursing staff, including an RN and a restorative aide, acknowledged receiving complaints that residents were not getting baths as scheduled and stated that residents sometimes went more than a week without a bath, and that missed baths could contribute to odors, dignity concerns, and skin conditions. The DON stated she expected residents to be bathed according to their care plan preferences and that refusals should be documented, but she was aware of prior grievances about missed baths. The facility’s bathing policy stated that residents have the right to choose the timing and frequency of bathing and required documentation of bathing activity or refusals and reapproach after refusals, but the documented patterns and interviews showed that these requirements were not consistently met.
Failure to Provide Planned Restorative Nursing Programs for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide ongoing restorative nursing programs as care planned and ordered for two cognitively intact residents with limited ROM and mobility. One resident, with Type 2 DM with diabetic neuropathy, an above-knee amputation, adjustment disorder with depressed mood, and stage 4 CKD requiring dialysis three times weekly, reported frustration that the fingers on her right hand were stiff and that she could no longer make a fist. She stated she felt weaker and believed she was not receiving the exercises she needed, explaining that she previously had exercises but no longer was brought for them. She reported that when she complained to therapy about not getting her exercises, she was told that restorative nursing aides were now responsible for providing them. Record review for this resident showed a physician note directing staff to encourage participation in restorative activities and a physician’s order for staff to encourage restorative activity three times weekly with a progress note to be completed on day shift when done. Her care plan included participation in restorative therapy with a goal to maintain current functional ability and interventions of AROM per therapy and nursing recommendations. Her MDS documented functional limitations in ROM in one upper and one lower extremity and indicated she received only two days of AROM restorative nursing programs in the seven-day look-back period. Restorative documentation from mid-December through late March showed that for lower extremity exercises she was documented as not available on multiple days, refused on several days, and not applicable on others, with only two days of restorative lower extremity exercises provided. For kinetic bike exercises over a three‑month period, she was documented as not available or refusing on multiple days, with several days marked not applicable, and only four days of kinetic bike restorative exercises completed. A second resident, who used a power wheelchair, had limited use of upper and lower extremities, and diagnoses including rheumatoid arthritis, polyneuropathy, and fractures of the right lower leg and foot, reported via an iPad translation device that she had participated in PT on admission and was discharged to a restorative program. She stated she was upset that she had not been receiving her exercise program, had complained to the DOR, and felt she was losing strength and her ability to stand and transfer. Her BIMS score indicated she was cognitively intact. Her MDS showed functional limitation in ROM in one lower extremity and no restorative nursing exercise programs received. Her care plan called for participation in a restorative therapy program to maintain functional abilities, with interventions including AROM, sitting exercises with a 3‑lb green TheraBand, trunk exercises x15 reps, and transfers involving standing with a walker up to 10 minutes. Restorative documentation from late January through late March showed multiple refusals and days marked not applicable, with no documentation that she received lower extremity exercises or stood with her walker for ten minutes during that period. Interviews with therapy staff and restorative aides revealed that therapy had provided written restorative recommendations on transfer forms, and the DON was responsible for setting up the programs. The therapy team expected two restorative aides to complete the recommended exercise programs, including upper and lower extremity exercises three to six times per week for the first resident (arm bike, recumbent kinetic bike, 5‑lb weights, green bands) and a lower extremity program three to six times per week for the second resident (standing with walker for ten minutes, 3‑lb weights, green bands). One restorative aide reported that she and the other aide were responsible for restorative exercises for about 44 residents, each scheduled for 15 minutes daily, and that it was impossible to see all residents when only one aide was working. She stated some residents were prioritized because they were ready, independent in getting to the exercise room, and enjoyed exercising, while others known to refuse were deprioritized when staff were busy. She acknowledged not having completed restorative exercises with the first resident recently and not having done restorative exercises with the second resident in over a month. The other restorative aide confirmed workload challenges, restrictions on being alone with the first resident, difficulty coordinating use of the main therapy room and equipment, and uncertainty about when either resident last received restorative exercises. The DON and regional nurse consultant confirmed that the facility’s policy defined restorative nursing as interventions to promote optimal functioning, that residents with written programs were expected to receive at least 15 minutes per day, and that the first resident had received only seven days of restorative exercises since mid‑December while the second resident appeared to have received none since late January, and they were unaware of the residents’ concerns.
Failure to Maintain Resident Dignity, Hygiene, and Privacy During Personal Care
Penalty
Summary
The deficiency involves failures to maintain resident dignity, hygiene, and privacy for multiple residents who were dependent on staff for personal care. One resident with severely impaired cognition, depression, and senile degeneration of the brain was dependent on staff for dressing, personal hygiene, and transfers with a full body lift. Her care plan required staff to use yes/no questions and clear explanations due to her communication difficulties. Her family reported concerns that she was not being changed regularly, was left in bed in her nightgown until mid-afternoon, and was not assisted out of bed to the dining room for meals. The family also reported finding dried juice on the resident’s stomach and bed sheets on consecutive days, indicating the linens had not been changed, and later finding the resident in bed around mid-afternoon in pajamas with food on her face and clothing. During the survey, the resident was observed in the afternoon with a dried green substance on her nose that remained there over an extended period, despite her dependence on staff for hygiene. Another resident with severely impaired cognition, unclear speech at times, and dependence on staff for personal and oral hygiene and dressing was repeatedly observed with soiled clothing and unclean hands and face. He was first seen lying in bed wearing a white shirt with multiple brown discolorations on the chest and arms. Later the same day, he was observed in the dining room wearing the same soiled shirt and spilling coffee repeatedly onto his clothing protector and shirt without staff offering assistance or interventions to prevent further spillage. That afternoon, he was again observed in bed wearing the same dirty shirt with food in his beard and stated he would have liked staff to change his shirt and that he had trouble with spilling food and drinks and wanted more assistance with eating and drinking. On another day, he was observed twice in the hallway with food in his beard and a thick orange substance on his fingers around his fingernails, as well as food on his shirt, with no indication in the record that he had refused clothing changes or hand and face washing. A third resident with severely impaired cognition, depression, anxiety, and a care plan noting severe mental illness with risk for abuse and neglect did not receive adequate privacy during incontinence care. Two CNAs assisted this resident in his shared room by placing a gait belt, helping him stand at the sink, lowering his pants, removing his incontinence brief, cleaning his private areas, and applying a new brief while his roommate was in bed. The privacy curtain was not pulled far enough to prevent the roommate from seeing the resident, and the window blinds were open, leaving him exposed during personal care. Staff interviews confirmed that residents’ clothing should be changed when soiled, faces and hands washed after meals or when soiled, refusals documented, and privacy ensured by closing doors, blinds, and curtains during personal care. The observations and interviews showed that these expectations and the facility’s dignity and privacy policy were not followed for these residents.
Resident Left in Dining Room for Extended Period Without Required Care
Penalty
Summary
The deficiency involves a resident with severe cognitive impairment who was left in the dining room for approximately ten hours without receiving care as outlined in his care plan. According to the SD DOH Facility Reported Incident, the resident was brought to the dining room at around 8:30 a.m. and was not taken back to his room until 6:31 p.m. that day. During this period, the resident did not receive identified interventions to meet his care needs from the CNA and LPN assigned to him. The facility’s investigation determined that the resident was neglected because his care plan was not followed and necessary care was not provided for an extended period. The resident’s medical record showed he had a BIMS score of 1, indicating severely impaired cognition, and diagnoses of metabolic encephalopathy and dementia. His care plan documented that he was at risk for skin impairment due to a history of stage II pressure ulcers, required repositioning every two hours and as needed, had a urinary catheter with urine output to be documented each shift, and required substantial assistance with toileting hygiene every two to three hours, transferring, and wheelchair mobility. He was also identified as being at risk for falls and was to be treated with respect and dignity and to reside free of mistreatment. Despite these documented needs, the resident remained in the dining room for about ten hours without the planned care being provided. The FRI report noted that the resident had a urinary catheter, could move and readjust himself in his wheelchair, was forgetful, and needed staff assistance with using the bathroom. Although his skin assessment after the incident did not show skin breakdown related to the event and he was not incontinent of bowels, the facility’s investigation concluded that the failure of the assigned CNA to follow the care plan and provide care during the prolonged period in the dining room constituted neglect. Interviews with the DON confirmed that the facility’s investigation found the resident had been neglected by staff on that day because his care needs, as specified in his care plan, were not met for approximately ten hours.
Failure to Follow Care Plan Requiring Two Caregivers During Resident Care
Penalty
Summary
Non-compliance at F684 occurred when a resident who was care planned to receive all care from two caregivers at all times was assisted by a single CNA. The resident had a documented history of making allegations of staff being rough and was identified in the care plan as requiring "cares in pairs" with two caregivers present to address her needs and observe the entire care session. Despite this, the CNA entered the resident’s room alone and began providing care without a second staff member present, contrary to the resident’s care plan and the facility’s expectations. The resident’s care plan, initiated on 10/28/22, identified manipulative behavior and alleged mistreatment as focus areas, noting that the resident might voice allegations of mistreatment or exploitation by caregivers, related to feelings of loss of independence, and might use abusive language. Interventions included assuring the resident she was safe and secure, providing two caregivers to address her needs and observe the entire session, having supervisory personnel observe care delivery as much as possible, and offering staff of certain racial backgrounds when able, based on the resident’s stated preferences and history of accusations. On the date of the incident, the resident reported to an LPN that the CNA had been rough with her during care that was provided without a second caregiver present. Staff interviews confirmed that the resident was known to make accusations, tell inconsistent stories, and sometimes scream even before being touched, and that she was to always receive care with two staff present because of these behaviors and prior allegations. On the day of the incident, staff on duty reported hearing the resident screaming after the CNA entered the room and began helping her, then left to get a second person to assist. The CNA acknowledged going into the room alone and assisting the resident with care, thereby not following the resident’s care plan requirement for two caregivers to be present during care, which led to the cited deficiency under F684.
Improper Mechanical Lift Use and Inadequate Sling Selection for Dependent Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of total body mechanical lifts and appropriate slings for residents requiring two-person assistance for transfers. Contracted travel CNAs and facility CNAs used incompatible or improperly sized and positioned slings, and staff lacked clear, accessible information on which sling size and type to use for specific residents. Surveyors identified that staff often selected sling sizes based on visual estimation of body size or by using whatever sling was present in the room, rather than following resident-specific guidance. Care plans and Kardexes for multiple residents who required mechanical lifts did not specify the type of lift (full body or sit-to-stand) or the correct sling size, leaving staff without written direction. One incident involved a resident who had been admitted earlier that day with a full body lift sling brought from the hospital. During a transfer from wheelchair to bed using a full body lift, two CNAs attached the sling provided by the family and began the transfer. As one CNA attached the lower body sling straps to the lift hooks, the resident moved and slid forward in the sling. The CNAs readjusted the resident and completed attaching the sling, but the resident continued to move and slid toward the edge of the wheelchair seat, causing the sling to tilt downward. Unable to safely complete the transfer, the CNAs lowered the resident to the floor using the upper portion of the sling while the lower portion remained attached to the lift. The resident’s buttocks contacted the floor first, she was then assisted to a lying position, and she reported rib pain; a subsequent chest X-ray showed no breaks or fractures. This event was identified as the start of Immediate Jeopardy at F689. Another observed incident involved a different resident being transferred from a wheelchair to a bed using a full body lift and a burgundy (large) sling. Two contracted travel CNAs placed the sling behind the resident, pulled the lower straps under her thighs, and interlaced the straps. As they began lifting, the resident’s wheelchair pad and the left handle of the wheelchair became caught in the sling, causing the wheelchair to lift off the floor with the resident still seated. While the resident and wheelchair were suspended, one CNA pulled on the wheelchair pad to free it, and the CNAs switched tasks while the resident remained in the air. After lowering the resident and wheelchair back to the floor and freeing the wheelchair handle, they did not reposition the sling, which was noted to be placed too high, with the bottom of the sling at the resident’s mid-back instead of under her buttocks. They then lifted the resident again and transferred her to the bed, with one CNA stating during the lift that the setup was “all wrong.” Interviews with multiple CNAs and nursing staff revealed that many had not received recent or any facility-specific training or competencies on safe use of mechanical lifts and sit-to-stand lifts. Several CNAs reported choosing sling sizes based on the resident’s body type or guessing, and one CNA stated she relied on training from previous employers. Staff were generally unaware of which sling to use for specific residents and could not readily locate up-to-date written resources; binders that were supposed to contain lift and sling information were missing or outdated. A paper list of sling sizes found in a communication binder was acknowledged by an RN as not updated. Another RN stated she did not know residents’ sling sizes and would ask a CNA for guidance. Record review confirmed that not all direct care staff, including CNAs involved in the incidents, had completed required competencies on total body lifts or sit-to-stand lifts after the reported incident, despite having worked shifts since that time. Further review of resident records showed that for several residents who used mechanical lifts, care plans and Kardexes lacked documentation of sling size and, in some cases, did not even specify the type of lift to be used. For example, one resident’s care plan and Kardex indicated a need for two-person assistance with transfers but did not identify any transfer equipment. Surveyors also compared an updated list of transfer equipment to slings stored in residents’ rooms and found discrepancies between listed sling sizes and those actually present or documented in the Kardex for certain residents. The facility’s own sling sizing chart and manufacturer’s instructions for the EZ Way Smart Lift outlined proper sling positioning and sizing parameters, including that the base of the sling should be positioned two inches below the tailbone and the top parallel with the shoulder line, but observed practice and staff statements demonstrated that these guidelines were not consistently followed.
Resident Left Unattended on Toilet Resulting in Potential Neglect
Penalty
Summary
The deficiency involves a resident being left unattended on a toilet in the beauty shop bathroom for an extended period, despite requiring staff assistance and supervision. The resident was later found by the charge nurse sitting on the toilet with the sit-to-stand lift still attached, the bathroom door closed, and the call light not activated. Prior to this, a CNA had noticed the resident’s room call light on, but the resident was not in his room; the CNA turned off the call light and proceeded to answer other call lights without locating the resident. The facility’s investigation identified that a certified medication aide (CMA) had taken the resident to the beauty shop bathroom earlier in the afternoon but did not inform other staff or acknowledge doing so, even though witnesses reported seeing the CMA escort the resident to that bathroom. The resident’s medical record showed moderately impaired cognition with a BIMS score of 8, diagnoses including Parkinson’s disease, unspecified dementia, hallucinations, and sensorineural hearing loss, and a high fall risk with a Morse fall scale score of 75. The care plan documented the need for a sit-to-stand lift for transfers, maximal/substantial assistance for toileting, and dependence on staff for toileting hygiene, as well as a focus on risk for pressure ulcer development related to immobility and incontinence. A Braden scale score of 13 indicated moderate risk for pressure ulcers. After being left on the toilet for an unknown but extended time, the resident was assessed by the charge nurse and found to have slight redness on the buttocks consistent with prolonged sitting on the toilet seat; the redness resolved before the end of the shift. There was no documented pain assessment or skin assessment in the medical record following this incident. Staff interviews revealed inconsistent practices and lack of clear guidance regarding monitoring residents left on toilets. One CNA reported checking assigned residents every two hours and returning to the bathroom within five to ten minutes if a resident did not use the call light, noting that longer periods on the toilet could cause redness from pressure. Another CNA stated that some resident bathrooms were too small for lift equipment, so residents were taken to the beauty shop bathroom, but there was no specific process or policy on when staff should return to assist residents off the toilet; she relied on remembering to go back. During observation, a staff member transferred a resident into the beauty shop and closed the door without changing the door sign from “Vacant” to “Occupied.” The facility’s neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and outlined procedures for investigation and protection of residents, but there was no documentation that audits were conducted to ensure staff understood and implemented resident safety interventions related to this incident.
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