St William's Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milbank, South Dakota.
- Location
- 103 N Viola St, Milbank, South Dakota 57252
- CMS Provider Number
- 435122
- Inspections on file
- 17
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at St William's Care Center during CMS and state inspections, most recent first.
A resident with MS, non-ambulatory status, a mild Braden risk score, and an existing unstageable left heel pressure ulcer had a care plan and MD orders requiring frequent repositioning, use of an air mattress and cushions, and heel boots each shift. Over multiple observations, the resident was seen in a wheelchair, recliner, and in bed for extended periods without heel boots or heel offloading, and staff did not reapply the heel boot after wound care. CNAs and a medication aide relied on CNA sheets that lacked specific instructions for heel boots and hourly repositioning in a chair, and one CNA reported only using heel boots in the wheelchair, not in bed or a recliner. The DON confirmed the ulcer originated after ACE wrap use for edema and acknowledged that the ordered repositioning frequency and care plan interventions were not being implemented.
Dietary staff failed to follow dietitian-approved menus and serving sizes for resident meals. A cook routinely served reduced portions of vegetables, side dishes, and protein without consulting the menu, used smaller scoops than required, and varied chicken portions based on resident gender, even when diet cards did not indicate small portions. Menu review showed required serving sizes of three ounces of protein and four ounces of vegetables or pureed items, with no formal small-portion diet, despite several residents requesting smaller portions. The dietary manager reported that staff were expected to use menu books and a binder with serving sizes, but a newly hired dietary aide, trained by the same cook, was also observed serving only two-ounce portions of mashed potatoes and ground beef instead of the ordered amounts.
Surveyors identified multiple food safety and sanitation failures, including staff using the same disposable gloves to handle surfaces and then directly touch RTE food and dishware, and a dietary aide preparing deli sandwiches for staff and residents without changing gloves or performing hand hygiene after leaving and re-entering the kitchen. Thermometer probes were stored in sanitizer containing food debris and were wiped on a cloth instead of being sanitized with alcohol wipes before checking food temperatures. The kitchen and walk-in cooler had heavy dust on vents, fans, ceilings, and light fixtures, and the commercial dishwasher had significant food scum and limescale buildup, with many missed deliming sessions and numerous undocumented dish machine temperatures despite policy requirements. Potentially hazardous foods were left at room temperature for extended periods, raw bacon was stored above RTE mashed potatoes, frozen beef patties were left uncovered in the freezer, and multiple expired or visibly spoiled items, including flavor extracts, food coloring, coffee syrups, relish, and dressing with apparent mold, were found in storage without appropriate dating or rotation.
Surveyors found that the facility failed to implement a formal water management program for Legionella. The maintenance director maintained the in-line water heater at 117–118°F, below the 122–125°F range required for Legionella control, did not add chemicals for Legionella prevention, did not test building water for chlorine, and had no documented plan for flushing stagnant water in empty rooms. A city water employee confirmed chlorine testing was done only at an upstream site, not at the facility. The DON/infection preventionist and the administrator both stated they expected maintenance to follow federal Legionella guidelines, but the administrator acknowledged that staff turnover led to no monitoring, no formal process for flushing stagnant water, and no system to ensure appropriate water temperatures. The Infection Prevention and Control Policy in effect did not address Legionella management or prevention, creating a facility-wide deficiency with potential impact on all residents, staff, and visitors.
A resident received fast-acting insulin from an LPN before breakfast, and despite staff expectations that the resident would be awakened, have the meal tray set up, and eat within 20–30 minutes, observations later that morning showed the resident still asleep with an untouched tray and no documented blood glucose monitoring. In a separate case, another resident routinely wore bilateral compression stockings applied by staff for lower extremity edema, but review of the EMR and TAR showed no active MD order for the stockings despite prior related orders being discontinued, and the DON confirmed an order and treatment entry should have been present; the facility also lacked a policy for transcribing and communicating MD orders.
Surveyors found that medications and medical supplies were not properly stored, labeled, or secured. In the medication room, multiple expired respiratory test swabs, wound culture supplies, catheter drainage bags, self-cath kits, female straight catheters, and emergency airway/oxygen items in the code box were present, even though the code box had been used on a resident the previous day. On two medication carts, several residents’ insulin pens and inhalers were opened or in use but not dated, and two opened glucose test strip bottles were also undated. Staff, including an LPN/DON in training and the DON, described expectations that insulin pens and inhalers be dated and carts checked regularly, while a pharmacist confirmed insulin should be dated once removed from refrigeration. Surveyors additionally observed two medication carts left unlocked and unattended in hallways, one with a resident sitting in front of it, despite facility policy requiring carts to remain locked or under visual control when not in close proximity.
A resident with Alzheimer’s disease, moderate cognitive impairment, a prior elopement, and a care plan requiring a wander guard and frequent checks exited the building unsupervised after the wander guard system alarmed. Although alarms sounded at the exit door, at a panel, and alerts were intended for staff radios, on-duty staff did not promptly respond because some were not near the panel, some did not hear or carry radios, and one staff member had a radio on the wrong channel. Other staff, including a ward secretary and a travel CNA who had not been re-educated, were observed silencing door panel alarms after only reviewing cameras or without understanding the alarm’s purpose, and did not physically check doors. Documentation showed the resident’s wander guard checks were either missing or performed only once daily despite orders for three checks per day, and interviews revealed inconsistent staff understanding of elopement procedures and alarm response.
A resident with heart failure and intact cognition was observed independently applying NC oxygen and using an oxygen concentrator set at 1.3 L/min, despite no physician order for supplemental oxygen following readmission. Staff and record review showed only an order to check oxygen saturation three times daily and to withhold oxygen if saturation was above 90%, with no order specifying NC use, flow rate, or parameters for when to initiate oxygen. CNAs relied on nurses for concentrator settings, and a CNA pocket care plan simply stated the resident was to have oxygen at all times. The resident’s room lacked an “oxygen in use” sign, and there were no orders or documentation for changing NC tubing or cleaning the bubbler, contrary to the facility’s oxygen therapy policy requiring signage and weekly humidifier/bubbler cleansing.
A resident with PTSD had a completed PASRR Level II review approving a time-limited stay, but this determination was not incorporated into the resident’s MDS comprehensive or quarterly assessments, which both indicated no PASRR Level II had been done. The SW completed and kept PASRR documentation in her office, did not share it with the IDT or the RN/MDS coordinator, and believed she only needed to communicate PASRR recommendations. The RN/MDS coordinator reported there was no process to identify completed PASRR Level II reviews and was unaware that the SW completed them, resulting in the PASRR Level II not being reflected in the MDS despite facility policy requiring PASRR approval prior to admission.
The facility failed to ensure the medical director attended and meaningfully participated in QAA meetings at least quarterly as required. The administrator reported that the QAA committee meets monthly and that she routinely texted the medical director reminders; he usually replied with topics for discussion and only occasionally joined by phone. Documentation showed the medical director attended one meeting in person and one by telephone during the review period, while for all other months he either did not attend or only sent topics via text. Facility policy identified the medical director as a QAA committee member and required the committee to meet at least quarterly.
An incident of alleged staff-to-resident sexual abuse occurred when a CNA was rough while cleaning a resident, causing pain inappropriately. The resident, who was cognitively intact, reported the incident, leading to the CNA's suspension and termination. Despite the report, there was no indication of new interventions or recent abuse education for staff. The facility's response included notifying relevant parties and conducting an investigation, but gaps in documentation and communication were noted.
The facility failed to provide timely Medicare notices for two residents discharged from skilled services. One resident's SNF ABN was completed a day before the end of services, and the NOMNC form was outdated. Another resident's SNF ABN was completed on the last day of coverage, also using an outdated NOMNC form. The social services designee was aware of the 48-hour notice requirement but not of the outdated forms.
Two residents experienced medication administration errors due to an LPN not following physician orders, resulting in a 5.13% error rate. The LPN administered incorrect doses of naproxen sodium and brimonidine tartrate, intending to verify the correct doses with the physician later. The DON expected staff to verify orders before administration, but the facility's policy lacked guidance on handling dosing discrepancies.
The facility failed to serve room trays at satisfactory temperatures, with residents reporting cold meals. Observations showed delayed meal service and test trays confirmed inappropriate food temperatures. Staff interviews revealed poor communication and documentation of food complaints.
A resident was transferred to the hospital without receiving a bed-hold notice, as required by facility policy. Interviews revealed confusion over responsibility for issuing the notice, and policy reviews showed inconsistencies in bed-hold procedures.
A CNA in a LTC facility was reported to have verbally and physically abused three residents, including telling a resident to 'shut up' and forcefully sitting another resident back into a wheelchair. The incidents were not documented in the residents' progress notes, and their families were not informed. The facility's policies on abuse and neglect were not adequately followed, and communication among staff was insufficient.
A housekeeper in an LTC facility wrongfully took a resident's clothes without permission, violating the resident's rights. The clothes were found in the housekeeper's closet, and the family had not agreed to discard them. The housekeeper admitted to taking the items, claiming they were donated and not new.
The facility failed to report two incidents of alleged abuse involving two residents to the required entities within the required timeframe. Although a CNA was aware of the correct reporting procedures, the incidents were not reported to the South Dakota Department of Health as mandated by the facility's policy. The administrator was informed of the incidents but did not take the necessary steps to report them.
The facility failed to investigate two reported allegations of abuse involving a CNA and two residents. The administrator was informed of the incidents but did not report them to the required entities or conduct a thorough investigation, citing confidentiality concerns. The facility's policy requires immediate reporting and investigation of such incidents, which was not followed in this case.
A facility failed to securely store Tramadol, a controlled medication, for a resident. Interviews and observations revealed that Tramadol was kept in a single-locked drawer with other scheduled medications, contrary to the facility's policy requiring double-lock storage. The director of nursing acknowledged this practice did not comply with their Controlled Substance-Narcotic Medication Management Policy.
Failure to Implement Ordered Heel Offloading and Repositioning for Resident With Unstageable Heel Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow pressure ulcer prevention and treatment interventions for a resident with an existing unstageable pressure ulcer on the left heel and identified risk for pressure injury. The resident had multiple sclerosis, was non-ambulatory and confined to bed or chair, and had Braden scores of 16–17 indicating mild risk. Her care plan, initiated 12/9/25, documented fragile skin, an existing unstageable left heel pressure injury, and directed staff to reposition her at least every hour when in a chair and every two hours at night in bed, and to use pressure-reducing devices including an air mattress, wheelchair/recliner cushion, and heel boots to the left foot as needed. Physician orders included daily wound cleansing and moisturizing cream to the left heel and an order from 8/2/22 for heel boots to be placed every morning, afternoon, and night shift. Surveyor observations over multiple days showed the resident repeatedly seated or lying without heel boots or other heel offloading while remaining in the same position for extended periods. On several occasions, she was observed in her wheelchair or recliner for hours without heel boots, and at one point lying in bed on her back with no heel boots or pillows to offload her heels, remaining in the same position for approximately two and a half hours. During a wound care observation, the DON and wound nurse removed the heel boot to perform care and did not reapply it afterward. Staff interviews confirmed that the wound nurse had instructed staff to leave the heel wound open to air and use a heel boot for cushioning, but this was not consistently done. Additional interviews and record review revealed systemic gaps in communicating and implementing the resident’s pressure ulcer interventions. CNAs and a medication aide reported relying on CNA sheets for direction on repositioning and use of pressure-relieving devices. The CNA sheet for this resident did not include her specific pressure ulcer interventions, such as hourly repositioning in a chair or the need for heel boots, and only directed staff to monitor skin, lay her down after meals, use an air mattress, and place a cushion in her chair. One CNA stated she only applied heel boots when the resident was in her wheelchair and did not understand the need for them in bed or a recliner. The DON acknowledged that the resident’s heel ulcer began as a blister associated with ACE wrap use for edema and stated that residents should ideally be repositioned every two hours, also acknowledging that the care plan directive for hourly repositioning in a chair was not being followed and that care plans should reflect current care needs.
Failure to Follow Dietitian-Approved Menus and Serving Sizes for Resident Meals
Penalty
Summary
The deficiency involves dietary staff failing to follow dietitian-approved menus and prescribed serving sizes for residents’ meals. During a lunchtime observation in the kitchen, a cook reported that most residents requested smaller portions and stated she typically served about four ounces of meat and two ounces of vegetables or side dishes, without referencing the dietitian-approved menu to verify correct serving sizes for each prescribed diet. In the dining room, the same cook was observed using a four-ounce scoop for peas and two-ounce scoops for pureed peas, stewed tomatoes, and mashed potatoes, but only serving one two-ounce scoop of these items instead of the menu-required four ounces. She also served smaller chicken legs to female residents and larger bone-in chicken breasts to male residents, and provided one resident with one scoop of peas (about four ounces), one scoop of mashed potatoes (about two ounces), one scoop of gravy (about two ounces), one slice of bread, and one small chicken leg, despite the resident’s laminated diet card not indicating any request for small portions. Review of the dietary extension menus showed that the menu for the observed day required three ounces of protein, a half-cup (four ounces) of mashed potatoes, and a half-cup of stewed tomatoes or peas, including a half-cup of pureed peas for residents on pureed diets, and that there was no designated small portions diet. A diet orders report indicated that seven residents had requested small portions and two residents were on pureed diets. The dietary manager stated that staff were expected to use a menu book and a binder labeled “Cold Orders” that contained menus and serving sizes for each diet, and that all dietary staff should know how to access and use these diet menu spreadsheets. On a separate observation day, a newly hired dietary aide was seen using a two-ounce scoop for mashed potatoes and ground beef and serving only one scoop of each to residents, after being helped with hot-holding table setup by the same cook. Review of the provider’s menu for that day showed that residents should have received a half-cup (about four ounces) of mashed potatoes and three ounces of roast beef or ground beef for mechanical soft diets, which was not followed.
Widespread Food Safety, Sanitation, and Documentation Failures in Dietary Services
Penalty
Summary
The deficiency involves multiple failures in food handling and glove use, thermometer sanitation, kitchen cleanliness, dish machine temperature monitoring, food storage, and disposal of expired or spoiled food. During breakfast and lunch meal service, a cook and dietary aides wore single-use gloves but did not change them between tasks or after touching potentially contaminated surfaces. With the same gloves, they handled serving utensils, laminated diet tickets, serving tables, aprons, cart handles, and then directly touched food-contact surfaces of plates, slices of toast and bread, and the drinking surfaces of cups. One cook also scooped loose brown sugar into containers with a gloved hand instead of using a utensil. Another dietary aide prepared deli sandwiches for staff and residents, touching bread, sandwich meat, cling wrap, and a permanent marker, then left the kitchen and returned to continue food preparation without changing gloves or performing hand hygiene, despite facility policies stating that gloved hands are a food-contact surface that can become contaminated and that gloves must be changed when soiled or when interruptions occur. The facility also failed to properly store and sanitize food thermometers and maintain a clean and sanitary kitchen environment. Two thermometer probes were stored in a cup of sanitizer solution that contained visible food debris and had not yet been changed from the previous day. Later, when checking the temperature of chicken, the cook wiped a thermometer probe on a cloth sitting on top of a container of papers instead of using available alcohol wipes, contrary to the dietary manager’s expectation that probes be cleaned with alcohol wipes before use. Observations in the kitchen and walk-in cooler revealed thick dust on ceiling vents above the walk-in cooler and freezer, dust accumulation on all four cooler fans and their grates, and dust on the cooler ceiling and light fixtures. The commercial dishwasher had a thick layer of food scum and limescale buildup on the inside of the doors and under the seam where it connected to the dirty dish table, and deliming records showed that several scheduled cleanings from July to December were missed, with only one deliming completed in December. Dish machine temperature logs showed numerous missed entries over several months, despite a policy requiring staff to monitor and record wash and rinse temperatures at each meal and for the director of food and nutrition services to spot-check the logs. From August through mid-February, there were repeated omissions in documenting required temperatures, and a dietary aide assigned to dishwashing duties stated he did not check the dish machine temperature and could not recall the last time he had done so. Food storage practices were also deficient. Cooked beef tips in gravy and beef patties intended for lunch were left on the counter at room temperature from before breakfast service until mid-morning, with measured temperatures in the danger zone, and the cook confirmed the food had been sitting out since before breakfast service began. In the walk-in cooler, raw bacon was stored in a box above RTE mashed potatoes, and in the walk-in freezer, a box of frozen beef patties was left uncovered and open to the air. Additionally, several baking ingredients and flavoring agents on a shelf were past their manufacturer best-by or expiry dates, and in the walk-in cooler, a jug of sweet pickle relish had a lid that was not fully secured and had an unidentified white substance on the inside, while a jug of thousand island dressing had apparent mold on the outside of the container, inside the lid, and on the handle, with no open date marked. The dietary manager stated she was unaware of these expired and potentially moldy items, despite a policy requiring rotation, dating, and monitoring of food to ensure timely use or disposal.
Failure to Implement Legionella Water Management Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the absence of a water management program to mitigate the growth and spread of Legionella. The maintenance director reported that he checked the in-line water heater temperature every morning and maintained it at 117–118°F, despite the requirement for water temperatures to be 122–125°F for Legionella control. He also stated that no chemicals were added to the water for Legionella prevention, the building’s water was not tested for chlorine levels, and there was no formal plan or documentation for flushing stagnant water in empty rooms, even though he or housekeeping sometimes ran the water and flushed toilets. Review of water heater temperature logs from November 2025 through February 2026 showed the water heater was consistently maintained at 117°F. A city water employee confirmed that chlorine testing was performed daily at a nearby upstream facility but not at this nursing home. The DON/infection preventionist stated she expected maintenance to follow federal guidelines for Legionella prevention, and the administrator similarly stated she expected maintenance to follow guidelines to prevent Legionella and acknowledged there had been a staff changeover with no one monitoring that the process was being done. The administrator further stated there was no formal process for running stagnant water or ensuring water temperatures were at levels needed to kill Legionella, and that she was responsible for ensuring the water management process was followed. Review of the facility’s Infection Prevention and Control Policy dated October 2025 showed it did not contain information regarding Legionella management and prevention. These findings demonstrated that the facility lacked a formal, implemented water management program for Legionella as part of its infection prevention and control program, with the potential to affect all residents, staff, and visitors.
Insulin Administration and Compression Stocking Orders Not Managed per Professional Standards
Penalty
Summary
The deficiency involves failure to ensure services met professional standards of quality for two residents. For one resident with diabetes, an LPN administered 5 units of Novolog, a fast-acting insulin, and 42 units of Toujeo, a long-acting insulin, when the resident’s blood glucose was 264 and before the resident had eaten breakfast. The LPN stated that after Novolog administration the resident should eat or drink within 20–30 minutes, and that staff were supposed to wake the resident, set up the room tray, and encourage eating. However, subsequent observations showed the resident remained asleep with an untouched breakfast tray at the bedside more than an hour after insulin administration, and the resident later reported that staff had not awakened her when the tray was delivered and that she had not eaten anything that day. A pharmacist and the DON both confirmed that food intake or blood glucose monitoring should occur within 20–30 minutes after Novolog administration, and the facility lacked an insulin administration policy. The second deficiency concerns failure to ensure a resident had a physician’s order in the EMR and on the TAR for compression stockings that staff were routinely applying. One resident was observed wearing bilateral compression stockings and reported staff put them on each morning to help with lower leg swelling. A CNA confirmed the resident was to wear bilateral compression stockings when out of bed for edema, but on a later observation the resident was not wearing them and stated staff had not applied them that morning. Review of the EMR showed prior and discontinued orders for TED hose, Ace wraps, and compression stockings, including an order to discontinue compression stockings after ankle measurements showed no change, and a later provider progress note referencing the resident going without compression stockings. There was no active physician order for compression stockings at the time staff were applying them, and the DON confirmed there should have been an order in the EMR and a corresponding treatment on the TAR. The facility did not have a policy regarding transcription and communication of physician orders to staff for implementation.
Improper Medication Storage, Labeling, and Security
Penalty
Summary
The deficiency involves failure to ensure medications and medical supplies were properly stored, secured, and labeled according to professional standards and facility policy. In the medication room, surveyors observed multiple expired medical supplies, including respiratory infection test swabs, a wound culture, urinary catheter drainage bags, self-catheterization kits, female straight catheters, and several emergency airway and oxygen delivery items stored in the code box. Staff reported the code box had been used the previous day on a resident. The LPN/DON in training stated that overnight nurses were responsible for checking outdates during downtime and that a medication aide checked weekly, and acknowledged that expired items should have been removed and that their sterility and function could not be guaranteed if used. On two medication carts, surveyors found multiple insulin pens and inhalers that were opened or in use but not dated, including insulin pens for three residents and inhalers for five residents, as well as two opened glucose test strip bottles that were not dated. The LPN/DON in training stated insulin pens should not be used past expiration and that insulin pens and inhalers were expected to be dated once opened, and that carts were to be checked weekly and by night nurses. Surveyors also observed two separate instances where medication carts were left unlocked and unattended in hallways, one with no staff nearby and another with a resident sitting in front of the cart, while the responsible RN and DON were in or approaching resident rooms. The DON initially stated she did not think insulin pens needed to be dated until used, but the consulting pharmacist stated insulin was to be dated once removed from the refrigerator. The facility’s Administration of Medication policy stated that medication carts should remain locked when the nurse is not in close proximity and that at least visual control must be maintained to prevent unauthorized access.
Failure to Respond to Wander Guard Alarms and Supervise an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident identified as at risk for elopement, who left the building unsupervised. On the evening of 9/18/25, the resident exited through the facility’s back door. The wander guard system activated, sounding an alarm at the door, at the alarm panel, and sending an alert to staff radios. However, staff did not respond promptly: no staff were in the area of the alarm panel, not all staff heard the radio alert, and the resident was ultimately noticed and reported by another resident’s family member who heard the alarm and contacted an off-duty staff member. That off-duty staff member then called the facility, and the on-duty nurse went out and brought the resident back inside. The resident involved had Alzheimer’s disease, a BIMS score of 9 indicating moderate cognitive impairment, a history of prior elopement, and a documented elopement risk assessment indicating she was at risk for elopement and should wear a wander guard and be checked frequently. Her care plan documented wandering, getting lost looking for her room, and wearing a wander guard on her walker, with staff instructed to monitor the wander guard and respond if she set off the alarm. The CNA sheets and a list in a binder identified her as wearing a wander guard. However, review of her treatment records from September and October 2025 showed no documentation that the wander guard was checked, and from November 2025 through mid‑February 2026, checks were only documented once daily at bedtime, despite an order for checks three times a day. Multiple interviews and observations showed inconsistent understanding and implementation of alarm and elopement procedures among staff. Some CNAs reported that when the door panel alarmed, they only reviewed cameras and silenced the alarm if they saw nothing suspicious, and did not always go to check the door. One ward secretary silenced an active alarm after reviewing cameras without physically checking any door. A travel CNA, who had not received education upon returning to the facility, silenced the alarm panel without knowing its purpose or investigating the cause. Staff reported varying beliefs about whether wander guard alerts went to radios, and some staff did not carry radios, had radios turned down, or had them on the wrong channel, resulting in missed alerts. The DON described expectations that nursing staff carry radios with adequate volume and that wander guard alarms at exit doors send alerts to radios, but also acknowledged that maintenance only checked door panels monthly and that the facility did not have a device to test wander guard function beyond checking placement. Education on elopement and alarm response was inconsistently provided, with documentation showing that not all staff received the elopement education in‑service.
Oxygen Therapy Provided Without Physician Order and Incomplete Oxygen Care Practices
Penalty
Summary
Surveyors identified a deficiency in which a resident was provided continuous supplemental oxygen via nasal cannula (NC) without a corresponding physician order following readmission from the hospital. Observations showed an oxygen concentrator in the resident’s room with attached NC tubing and a water-filled bubbler that were undated, with no indication of when they were provided or cleaned, and no “oxygen in use” sign posted outside the room. The resident, who had a diagnosis of heart failure and a BIMS score of 15 indicating she was cognitively intact, independently applied the NC and turned on the concentrator, which was set at 1.3 L/min, stating she was supposed to wear oxygen per her doctor’s order. During another observation, the resident again applied the NC and turned on the concentrator when the surveyor entered, and an LPN checked her oxygen saturation, which was 98%, but did not remove the NC or turn off the concentrator. Record review revealed an order on the treatment administration record (TAR) only to check the resident’s oxygen saturation three times daily and that supplemental oxygen was not needed if saturation was greater than 90%, but there was no physician order for oxygen via NC at 1 L/min if saturation was less than 90%, nor any orders to change the NC tubing or clean the bubbler. Staff interviews confirmed the absence of a physician order for oxygen therapy upon readmission and that CNAs relied on nurses to tell them how to set the concentrator. A CNA reported she was unaware of any specific oxygen order and only knew the resident was to have her NC on, and a CNA pocket care plan indicated the resident was to have “oxygen at all times,” without detailing parameters. The DON/infection preventionist stated the resident should have had an EMR order for oxygen via NC at 1 L/min if saturation was less than 90%, as well as TAR entries for weekly bubbler cleaning, twice-monthly NC tubing changes, and placement of an “oxygen in use” sign, which were not present. Policy review showed the facility’s oxygen therapy policy required an “OXYGEN IN USE” sign outside the room and weekly cleansing of the humidifier/bubbler, which were not being followed for this resident.
Failure to Integrate PASRR Level II Determination Into MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to incorporate a resident’s Level II PASRR determination into the MDS assessments and to coordinate this information with the interdisciplinary team. One resident with a diagnosis of PTSD was admitted to the facility and had both a comprehensive and a quarterly MDS assessment completed, each indicating that no PASRR Level II had been done. However, record review showed that the resident had, in fact, undergone a PASRR Level II review by the state’s contracted PASRR service, which approved a 180‑day stay with a specified end date. This PASRR Level II information was not reflected in the MDS, despite the facility’s admission policy requiring PASRR pre‑admission screening and approval for the appropriate level of care prior to admission. Interviews with staff revealed that there was no established process to ensure that completed PASRR Level II determinations were communicated to the RN/MDS coordinator or incorporated into the MDS. The social worker reported that she completed PASRR forms, kept them in her office, and did not share the completed PASRR documentation with the interdisciplinary team or the RN/MDS coordinator, stating that it did not occur to her that she needed to inform the MDS coordinator whether a resident was PASRR Level I or II. She indicated she only informed nursing of any PASRR recommendations and noted she had MDS permissions only for Section S. The RN/MDS coordinator confirmed there was no process to determine whether a PASRR Level II had been completed and that Section S does not trigger Section A of the MDS, and she was unaware that the social worker completed PASRR Level II reviews for residents.
Failure of Medical Director to Attend QAA Meetings at Least Quarterly
Penalty
Summary
The deficiency involves the facility’s failure to ensure the medical director attended and meaningfully participated in Quality Assessment and Assurance (QAA) committee meetings at least quarterly as required. During an interview, the administrator stated that the QAA committee meets monthly and that she texted the medical director each month to remind him of the meetings; he typically responded by texting topics for the committee to discuss and only sometimes attended by telephone. The administrator acknowledged she was aware that the medical director was required to attend at least quarterly and that he did not have a NP or PA to attend in his absence. Review of the QAA committee binder showed the medical director attended via telephone at the most recent meeting in late January 2026 and attended in person in mid-August 2025, but for all other months in 2025 he either did not attend or only sent texted topics instead of participating in the meetings. Review of the facility’s QAPI policy from July 2025 confirmed that the medical director was designated as a QAA committee member and that the committee was required to meet at least quarterly.
Alleged Staff-to-Resident Sexual Abuse Incident
Penalty
Summary
The report details an incident of alleged staff-to-resident sexual abuse involving a resident who was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The incident occurred when a certified nursing assistant (CNA) was cleaning the resident after she used the bathroom. The resident reported that the CNA was rough and caused pain by cleaning her vaginal area inappropriately. The resident expressed concern that the CNA's actions were intentional, as the CNA commented on the resident being dirty and needing to be cleaned to prevent infections. Following the incident, the resident was assessed by a licensed practical nurse (LPN) and subsequently transferred to a local emergency room for further evaluation. The facility's administrator and director of nursing (DON) were notified, and the CNA involved was suspended pending investigation and later terminated. Despite the resident's report, there was no indication of new or different interventions or care provided to her following the incident. Interviews with other staff members revealed a lack of awareness of any new interventions or recent abuse education, particularly regarding sexual abuse. The facility's response to the incident included notifying relevant parties and conducting an investigation. However, there were gaps in documentation and communication, as evidenced by the absence of a social services note in the resident's record and the lack of a completed SANE report. Additionally, there was no specific education or training on sexual abuse provided to staff following the incident, and the facility continued to use audits from a previous physical abuse incident. The report highlights the need for comprehensive abuse education and thorough documentation in handling such sensitive cases.
Failure to Provide Timely Medicare Notices
Penalty
Summary
The provider failed to ensure appropriate and timely Medicare notices were provided for two residents who were discharged from skilled services. For one resident, the Medicare Part A Skilled Episode began on 7/25/24, with the last covered day on 8/20/24. However, the SNF Advance Beneficiary Notice of Non-coverage (ABN) was completed on 8/19/24, not providing the required 48-hour notice prior to the end of services. Additionally, the Notice of Medicare Non-Coverage (NOMNC) form used was outdated and had an incorrect header. For the second resident, the Medicare Part A Skilled Episode started on 5/17/24, and the last covered day was 6/4/24, the same day the SNF ABN was completed and signed, again failing to meet the 48-hour notice requirement. The NOMNC form was also outdated and lacked the correct header. An interview with the social services designee revealed awareness of the 48-hour notice requirement but unawareness of the outdated forms.
Medication Administration Errors
Penalty
Summary
The provider failed to follow physician orders during medication administration for two residents, resulting in a medication error rate of 5.13%. For one resident, a licensed practical nurse (LPN) administered a 220 mg tablet of naproxen sodium instead of the prescribed 250 mg. The LPN acknowledged the discrepancy but proceeded to give the medication, intending to verify the correct dose with the physician later. In another instance, the same LPN administered one drop of brimonidine tartrate 0.2% solution into each eye of a resident, contrary to the physician's order of two drops per eye. Again, the LPN planned to confirm the correct dosing with the doctor after administration. The director of nursing (DON) stated that nurses are expected to verify physician orders with the medication administration records (MAR) before administering medications. The facility's policy on medication administration emphasized giving the correct medication at the appropriate dose and time but did not specify procedures for addressing discrepancies in dosing or orders. The lack of adherence to these protocols contributed to the medication errors observed during the survey.
Deficiency in Serving Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that room trays were served at a satisfactory temperature for residents who chose to eat meals in their rooms. Three residents reported that their meals were often cold by the time they were delivered. One resident mentioned that by the time her reheated food was returned, she had already finished the rest of her meal. Another resident, who was new to the facility, did not report the issue to staff to avoid causing trouble. The third resident also complained about cold food on his room tray. Observations during the survey revealed that the meal service in the dining room was delayed, with the first resident being served 27 minutes after the stated meal service time and the last resident 53 minutes later. The test trays delivered to the survey team showed that food items were not at appropriate temperatures, with some items being lukewarm or cold. The dietary manager acknowledged awareness of complaints about cold food on room trays and noted that the insulated carts work best if trays are served within 10 to 15 minutes. Interviews with staff revealed a lack of communication and documentation regarding food complaints. The dietary manager was not aware of complaints from the resident council meeting, and the social service designee did not keep records of verbal complaints or fill out concern forms for issues raised at the meetings. The administrator and DON were aware of the cold food complaints but did not use concern forms to document them. The policy on resident room trays was requested but not received by the end of the survey.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The provider failed to provide a bed-hold notice to a resident or their representative when the resident was transferred to the hospital. The deficiency was identified for one resident who was transferred to the hospital on August 13, 2024, and returned to the facility on August 19, 2024. Although the resident's power of attorney was notified of the transfer, there was no documentation that the bed-hold information was communicated to either the resident or their power of attorney. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing bed-hold notices. The social services designee stated that she had not received the bed-hold notice from the nurses and confirmed that it had not been completed. The director of nursing indicated that the social services designee was ultimately responsible for ensuring bed-hold notices were completed. A review of the facility's policies and admission documents showed inconsistencies and omissions regarding bed-hold procedures, particularly for Medicare residents.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The provider failed to protect three residents from mistreatment, intimidation, verbal abuse, and physical abuse by a certified nurse assistant (CNA). Resident 2, who was not feeling well and had vomited several times, was reportedly told to 'shut up' by CNA J and had her hands swatted away from her incontinence brief. This incident was witnessed by another CNA, although CNA J denied the allegations. Resident 2's medical records indicated she had anxiety disorder and dementia, which required specific care approaches that were not adhered to during the incident. Further incidents involved Resident 3 and Resident 4. Resident 3 was reportedly stuck behind a door, and CNA J was heard yelling and banging on the door. Resident 4, who had a history of falls and required assistance, was forcefully sat back into her wheelchair by CNA J after attempting to stand. This incident was witnessed by a nurse aide who reported that Resident 4 expressed fear towards CNA J, referring to him as 'a hateful person.' These actions were not documented in the residents' progress notes, and their families were not informed of the alleged abuse. The facility's policy on abuse, neglect, and misappropriation of resident property emphasizes the importance of treating residents with dignity and respect, and outlines procedures for reporting and investigating abuse. However, the incidents involving CNA J suggest a failure to adhere to these policies, as there were multiple reports of verbal and physical abuse that were not adequately addressed. The facility's investigation process and communication among staff were also found to be lacking, as evidenced by the administrator's failure to inform other department heads about the incidents.
Misappropriation of Resident Property by Housekeeper
Penalty
Summary
The provider failed to protect a resident's belongings from being wrongfully used by a housekeeper. On July 13, 2024, a bag of clothes belonging to a resident was found in the housekeeper's closet. The family of the resident had not given permission for the clothes to be discarded, indicating a violation of the resident's rights. Additionally, a shirt belonging to a recently deceased resident was also found in the same housekeeper's closet. The housekeeper admitted to taking the clothes without permission, claiming they were donated items and not new. The housekeeper had been previously spoken to about taking donated clothing home, which was intended for residents, not staff. The housekeeper stated that she did not obtain permission from the family through social services before removing items from resident rooms. This incident was reported to the administrator on July 15, 2024, and the required reporting was submitted on July 17, 2024. The failure to ensure the protection of resident property violated the resident's right to be free from misappropriation of property.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The provider failed to report allegations of abuse to the required entities within the required timeframe for two incidents involving two residents. A certified nursing assistant (CNA) was aware of the correct reporting procedures but had not reported any incidents recently. However, she was aware of two incidents involving another CNA and two residents, which were reported by a different CNA. The administrator was informed of these incidents by a nurse aide but did not report them to the South Dakota Department of Health (SD DOH) as required. The facility's policy mandates immediate reporting of alleged violations involving mistreatment, neglect, or abuse to the administrator and the SD DOH. Despite this, the incidents involving the two residents were not reported to the SD DOH or other required entities. The administrator acknowledged awareness of one incident and initially denied knowledge of the other but later recalled it. The facility's policy emphasizes the importance of reporting to prevent worsening situations or harm to residents, yet these procedures were not followed in these cases.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The provider failed to investigate two reported allegations of abuse involving two residents. The administrator was informed by a nurse aide about incidents involving a certified nursing assistant (CNA) being cross with residents. Despite being aware of the incidents, the administrator did not report them to the required entities or conduct a thorough investigation. The administrator admitted to not informing other department heads to maintain confidentiality and only informed the Director of Nursing (DON) about the situation. The administrator kept a daily log of conversations but could not recall when the incidents were reported. The facility's updated policy on abuse, neglect, and misappropriation of resident property outlines the process for identifying, investigating, and reporting alleged violations. The policy requires immediate reporting of incidents to the administrator and the South Dakota Department of Health, with specific timelines based on the severity of the incident. However, the administrator did not follow these procedures, failing to report or investigate the allegations involving the CNA and the two residents. The policy also emphasizes the protection of residents during investigations and the need for corrective actions if violations are verified.
Failure to Securely Store Controlled Medication
Penalty
Summary
The facility failed to adhere to its Controlled Substance-Narcotic Medication Management Policy by not securely storing a controlled medication, Tramadol, for a resident. During interviews, a medication aide revealed that Tramadol, a controlled substance, was stored in the same location as other scheduled medications and was not double-locked, contrary to the facility's policy. The aide acknowledged that while PRN controlled medications were stored in a double-locked drawer and counted at shift changes, scheduled controlled medications like Tramadol were not counted at shift changes and were not double-locked. Further interviews and observations confirmed that scheduled controlled medications, including Tramadol, were kept with other scheduled medications in a single-locked drawer of the medication cart. The director of nursing admitted that this practice did not comply with the facility's policy, which requires all scheduled II-V medications to be maintained in a separately locked, permanently affixed compartment. The policy also mandates that all controlled substances be counted at each shift change, which was not being followed for scheduled medications.
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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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