Strand-kjorsvig Community Rest Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Roslyn, South Dakota.
- Location
- 801 S Main, Roslyn, South Dakota 57261
- CMS Provider Number
- 435125
- Inspections on file
- 15
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Strand-kjorsvig Community Rest Home during CMS and state inspections, most recent first.
The facility did not maintain consistent on-site administrative oversight, with the administrator of record only present weekly and a secondary administrator covering once a week while also managing another facility. Most day-to-day management and administrative duties were delegated to the DON and business manager, leading to difficulties in fulfilling their primary responsibilities and impacting the quality management and well-being of all residents.
The facility did not ensure its QAPI program effectively identified and corrected quality deficiencies, as the QAPI committee and DON were unaware of multiple areas of non-compliance, including medication management, care planning, assessments, oxygen equipment handling, trauma-informed care, food storage, and infection control. The QAPI committee was only focused on a limited set of issues and failed to monitor or address several critical areas impacting resident care.
The QAA committee did not consistently include an administrator, owner, board member, or other leadership representative, as required. Over a 15-month period, the administrator attended only two meetings, and no other leadership figures were present, despite policy stating their responsibility for QAPI oversight. Department managers, the medical director, and the consultant pharmacist attended, but leadership involvement was lacking.
Several residents self-administered medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or required physician's orders. Medications were left at the bedside or in resident rooms, sometimes expired or unlabeled, and care plans did not address self-administration or medication storage. Facility staff confirmed that no residents had been formally assessed or authorized for self-administration, contrary to facility policy.
Several newly admitted residents did not have complete baseline care plans within 48 hours of admission, with missing documentation of review and provision to residents or their representatives. Some care plans lacked essential information such as active diagnoses and signatures, and residents reported not recalling any review or receipt of their care plans. The facility's policy did not require review of the baseline care plan with the resident or representative within the specified timeframe.
Surveyors found that care plans for several residents were not updated to reflect current care needs, including missing documentation of activity interests, therapy interventions, behavioral health strategies, self-administration of medications, and use of medical devices. Staff interviews revealed a lack of awareness and formal auditing of care plans, and facility policies requiring individualized, interdisciplinary care planning were not consistently followed.
A resident receiving antipsychotic medication did not receive a timely AIMS assessment as ordered by the physician, and the results were not communicated. Additionally, a resident with diabetes had multiple insulin doses held due to low blood sugar or lack of appetite, but the physician was not consistently notified, and there was no clear policy guiding these notifications. These actions resulted in deficiencies related to following physician orders and ensuring professional standards of quality.
The facility did not consistently follow its own policies for counting and documenting controlled medications, including those in emergency kits and those prescribed to individual residents. Required shift-to-shift counts and verification of tamper-evident tag numbers were frequently incomplete or missing, with forms lacking staff initials, tag numbers, and documentation for entire shifts. Staff and the DON confirmed gaps in documentation and acknowledged the absence of a system to record counts for individual residents' controlled medications, despite facility policies mandating these procedures.
Surveyors found that medications with shortened expiration dates were not properly labeled or disposed of after expiration, and expired medications remained in use. Medication labels often did not match current physician orders as documented in the MAR, and there was no consistent process to indicate dose changes on medication containers. Additionally, daily temperature monitoring and documentation for medication storage areas, including refrigerators, were incomplete or showed temperatures outside the acceptable range. Staff were aware of some requirements but did not consistently follow policies for medication management.
The facility did not ensure Enhanced Barrier Precautions (EBP) were followed for two residents with wounds, as required by its infection control policy. PPE such as gowns and gloves were not available at the point of care, staff inconsistently used PPE during high-contact activities, and there was confusion among staff about when and where EBP should be applied, including in therapy areas.
The facility did not follow its antibiotic stewardship policy, as the DON admitted to inconsistent use of required infection surveillance forms, lack of documentation of symptoms before contacting physicians, and failure to monitor infection trends or conduct required audits. The facility also did not complete annual summaries, hold stewardship meetings, or maintain an antibiogram, and the DON was unaware of elevated UTI rates among long-stay residents.
The designated infection preventionist, who was the DON, had not completed the required CDC infection prevention and control training, having finished only 5 of 23 modules and lacking a certificate of completion.
Surveyors found that two residents using respiratory devices did not receive proper infection control, cleaning, or documentation as required by facility policy. One resident's nebulizer was stored on the floor and not cleaned after each use, while another resident's CPAP lacked a physician order, care plan inclusion, and documented cleaning. Staff interviews revealed inconsistent practices and knowledge, and facility policies were not aligned with actual procedures.
Two residents with PTSD and moderate cognitive impairment were not assessed for trauma-related needs, and their care plans lacked interventions or strategies to address their mental health conditions. Staff interviews confirmed the absence of a trauma-informed care policy or assessment process, and documentation of mental health services was missing despite facility policy requirements.
Surveyors found that opened food containers in the kitchen were not dated and expired food items were not discarded, including undated cereal and expired cheese that had physically deteriorated. The dietary manager was unaware of these issues, despite facility policies requiring regular inspection, labeling, and removal of expired products.
A resident with a history of mental health issues was able to hide and later ingest multiple doses of Tylenol due to staff failing to supervise her medication intake. This resulted in her hospitalization for hypotension and liver failure. The facility's policy required staff to remain with residents during medication administration, which was not followed in this case.
A resident with a history of mental health issues was able to accumulate Tylenol tablets due to staff failing to ensure medication consumption, leading to a self-harm incident and hospitalization. The facility's policy required staff to remain with residents until medications were swallowed, which was not followed.
Inadequate Administrative Oversight and Delegation of Duties
Penalty
Summary
The facility failed to ensure effective and efficient use of its resources due to inadequate administrative oversight and inconsistent presence of the administrator. Administrator A, who was the administrator of record, was only present in the building weekly, and when unavailable, administrator B, who was also a full-time administrator at another facility, would be present once a week. Department managers such as the DON, business manager, and dietary manager were expected to be in the building full-time, but significant administrative duties were delegated to the DON and business manager. The DON reported struggling to fulfill her nursing responsibilities while also covering administrative tasks, and noted that administrator A's response to issues was not always timely. The business manager was unavailable during the survey for interview. Interviews with staff revealed that the day-to-day operations and quality management of the facility were largely handled by the DON and business manager, with administrators only intervening when issues arose that could not be addressed by these managers. The administrator job description required direct oversight and accountability for the facility's operations, but this was not consistently met. The lack of regular, on-site administrative supervision led to management issues being delegated to department heads, impacting their ability to perform their primary roles and potentially affecting the overall well-being of the 26 residents in the facility.
Failure to Identify and Address Quality Deficiencies Through QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified and corrected quality deficiencies throughout the facility. The Director of Nursing (DON) was responsible for overseeing the quality management program, including QAA committee meetings and QAPI projects. However, during an interview, the DON stated that while each department manager conducted audits and discussed them with the QAPI committee, the committee was only focused on a limited set of issues such as restraints, skin infections, call light accessibility, and communication with medical providers regarding lab results. The DON was unaware of several areas of non-compliance, including medication administration and storage, timely provision of baseline care plans, accurate care plan revisions, completion of required assessments, proper handling of oxygen equipment, trauma-informed care assessments, safe food storage, and infection prevention and control practices. The QAPI committee had not identified or addressed these significant quality issues, and the DON confirmed that the QAPI process had not been effective in identifying problems that could impact resident care. The facility's QAPI policy stated that the program should encompass all care and services affecting clinical care, quality of life, resident choice, and care transitions, and that the governing body and management were responsible for identifying and prioritizing problems based on performance data. Despite this, the QAPI committee was not aware of or monitoring several critical areas of deficiency, as confirmed by the DON.
QAA Committee Lacked Required Leadership Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee included the required members, specifically an administrator, owner, board member, or other individual in a leadership role, as mandated. Over a 15-month period, attendance records showed that the administrator attended only two QAA meetings, and there was no evidence that the owner, a board member, or another leadership designee attended any meetings. Interviews with the medical director and DON confirmed that the administrator was not routinely present at QAA or QAPI meetings, and the DON noted that the administrator had only recently attended a meeting after a prolonged absence. The QAA committee was otherwise comprised of department managers, the medical director, and the consultant pharmacist, but lacked consistent leadership representation. The facility's QAPI policy outlined that the governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program, including identifying and prioritizing problems, incorporating input from staff and residents, and ensuring corrective actions are effective. Despite these policy requirements, the facility did not provide evidence that leadership was actively involved in the QAA process during the review period, as required by regulation.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications were properly assessed for their ability to do so safely and did not obtain the required physician's orders for self-administration, as outlined in facility policy. Four residents were identified as self-administering medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or care plan interventions addressing their ability to self-administer. In several cases, medications were left at the bedside or in resident rooms without proper labeling or documentation, and some medications were expired or not prescribed for current use. One resident with moderate cognitive impairment was observed self-administering nebulizer treatments and using topical medications left at his bedside, including an expired antibiotic ear drop that he used for itching. He also had an antacid medication left at his bedside for self-administration without a physician's order or assessment. Another resident, who was cognitively intact, self-administered prescription cream and powder with physician's orders to keep the medications in his room, but there was no documentation of an assessment for his ability to self-administer these medications, nor was this addressed in his care plan. Additional residents were found to have medications such as Vicks Vapor Rub and nebulizer treatments in their rooms, which they self-administered without physician's orders or documented assessments. Facility staff, including LPNs and the DON, confirmed that no residents had been formally assessed for self-administration of medications and that physician's orders for self-administration were not in place. The facility's policies required both an assessment and a physician's order for self-administration, but these procedures were not followed, and the care plans did not address self-administration or medication storage for the affected residents.
Failure to Complete and Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and document baseline care plans and provide written summaries to residents or their representatives within 48 hours of admission for four recently admitted residents. Record reviews showed that baseline care plans were either incomplete, missing required sections such as active diagnoses, staff and resident signatures, or not documented as being reviewed with the resident or their representative. In several cases, there was no evidence that a copy of the baseline care plan was offered or provided to the resident or their representative. Interviews with the residents revealed that they did not recall reviewing their care plans or being offered copies within the required timeframe. Specific observations included residents with moderate cognitive impairment, use of medical devices such as CPAP machines and equalizer boots, and recent hospitalizations. The facility's policy required an interim plan of care to be developed within 24 hours of admission but did not specify that the plan must be reviewed with the resident or representative within 48 hours. The DON confirmed that several baseline care plans were incomplete and lacked documentation of review or provision to the residents or their representatives.
Failure to Update and Individualize Resident Care Plans
Penalty
Summary
Surveyors identified that the facility failed to ensure care plans were reviewed and revised to reflect the current care needs for seven of twelve sampled residents. Multiple observations, record reviews, and interviews revealed that care plans did not include essential information about residents' current conditions, interventions, and preferences. For example, one resident who spent significant time working on puzzles and was preparing for discharge had no documentation in his care plan regarding his activity interests or discharge plans. Another resident, who was on a therapy maintenance and positioning program requiring her feet to be elevated in a recliner, had no mention of this intervention in her care plan, and the director of nursing was unaware of the program's existence for this resident. Additional deficiencies were noted for residents with complex behavioral and medical needs. One resident with severe anxiety, pacing, and crying behaviors had no documentation in her care plan of non-pharmacological interventions or updates regarding the removal of bed rails, despite ongoing behavioral symptoms and changes in her care. Another resident self-administered topical medications as ordered by a physician, but this was not addressed in his care plan. Residents with mental health diagnoses, such as PTSD and major depressive disorder, also had care plans lacking interventions or strategies to address their specific behavioral health needs, including triggers and coping mechanisms. In one case, a resident's care plan did not reflect the use of a CPAP machine for obstructive sleep apnea, despite the resident's long-term use of the device. Interviews with staff, including the DON, LPNs, and social service designee, confirmed that care plan updates were primarily completed by the MDS nurse and that there was no formal audit process in place. Staff were often unaware of whether specific interventions or resident needs were included in the care plans. Facility policies required individualized, interdisciplinary care plans that addressed current needs and preferences, but these were not consistently followed, resulting in care plans that did not accurately reflect the residents' current care requirements.
Failure to Complete Physician-Ordered Assessments and Notify Physician of Held Insulin Doses
Penalty
Summary
A deficiency occurred when a physician-ordered Abnormal Involuntary Movement Scale (AIMS) assessment was not completed as required for a resident receiving antipsychotic medication. The resident, who was severely cognitively impaired and had diagnoses including Wernicke's Encephalopathy, anxiety disorder, amnestic disorder, and drug-induced subacute dyskinesia, exhibited abnormal movements such as hand tremors, constant leg movement, and restlessness. Despite a physician's order to complete an AIMS assessment and provide updates on mood, behaviors, and PRN Lorazepam use, there was no documentation that these assessments or communications were completed after the last recorded AIMS assessment. The DON confirmed that the required assessment and updates were not performed or communicated to the physician as ordered. Another deficiency was identified regarding the management of insulin for a resident with diabetes. The resident's insulin doses were repeatedly held due to low blood sugar readings or lack of appetite, but there was no physician order specifying parameters for when to hold insulin until later in the month. Documentation showed that the physician was not notified each time insulin was held, and staff interviews confirmed that notifications were not consistently made. The medical director stated that immediate notification was expected when insulin was held for hypoglycemia, but this did not occur. The facility lacked a policy specifically addressing physician notification for held or refused medications, and documentation of physician notification for the held insulin doses was not provided. Policy reviews revealed that while there were general protocols for physician visits, medication orders, diabetes management, and notification of resident changes, there were gaps in policies related to following physician orders unrelated to medications and specific guidance on physician notification for held or refused medications. The absence of clear documentation and communication with the physician regarding both the AIMS assessment and insulin management led to the deficiencies identified during the survey.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to follow its own policies and procedures for the management and documentation of controlled medications, specifically those stored in emergency kits (E-Kits) and in medication carts and refrigerators. Observations and interviews revealed that required shift-to-shift counts of controlled substances were not consistently documented by two staff members as required. Forms intended to record these counts and the verification of tamper-evident tag numbers on E-Kits were frequently incomplete, with missing staff initials, missing tag numbers, and days where no documentation was present at all. This pattern was observed across multiple months, with repeated instances of incomplete or missing documentation for both day and night shifts. Interviews with nursing staff confirmed that the expectation was for two staff members to count and document controlled medications at each shift change, including those in E-Kits and those prescribed to individual residents. However, staff acknowledged that there was no form or designated location to document the counts of controlled medications prescribed to individual residents, making it impossible to verify when or by whom these counts were completed. The Director of Nursing also confirmed this gap in documentation and was unaware of the frequency of missing or incomplete records for the E-Kit counts and tag verifications. Policy reviews showed that the facility's own procedures required controlled substances to be counted and documented by two staff members at every shift change, with specific forms to be used for this purpose. Despite these clear requirements, the facility did not ensure that documentation was complete or that all required counts were performed and recorded, resulting in a failure to properly account for controlled medications as mandated by facility policy.
Medication Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and administration of medications and biologicals. Medications with shortened expiration dates, such as inhalers and eye drops, were not consistently labeled with their opened or expiration dates, and some expired medications remained in medication carts for potential use. For example, opened Latanoprost eye drops and Trelegy Ellipta inhalers lacked proper documentation of opened and expiration dates, and expired Latanoprost eye drops were still present in the cart. Additionally, a stock supply of Silver Sulfadiazine cream was found to be opened for over a year without being discarded. There were discrepancies between medication labels and the current physician orders as documented in the medication administration records (MARs). Several medications, including gabapentin, midodrine, duloxetine, and insulin pens, had pharmacy labels that did not match the MARs, and there was no indication on the medication containers that the orders had changed. Staff, including LPNs and certified medication aides, reported that pharmacy did not replace labels when orders changed, and there was no consistent process to indicate dose changes on medication containers. This inconsistency made it difficult for staff to verify correct medication doses during administration. Temperature monitoring and documentation for medication storage areas were also found to be deficient. The refrigerator used to store medications had multiple days with missing temperature documentation throughout the year, and several days with recorded temperatures outside the acceptable range. The facility did not monitor or document the temperature of the room where medications were stored, contrary to policy requirements. The DON confirmed awareness of some issues, such as the need to date medications when opened, but was not aware of the extent of missing or out-of-range temperature documentation.
Failure to Implement Enhanced Barrier Precautions According to Policy
Penalty
Summary
Surveyors identified that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own infection prevention and control policy for two residents who were on EBP. Observations revealed that signage indicating EBP was present on the doors of both residents, but there was no personal protective equipment (PPE) such as gowns or gloves available at or near the entrances to their rooms. Staff interviews confirmed inconsistent understanding and application of EBP, with some staff unaware of the reasons for EBP signage or the correct PPE requirements, and others storing gowns in resident dressers or closets rather than at the point of care. For one resident, who had recently returned from the hospital with a surgical incision and staples, there was no documentation in the electronic medical record (EMR) indicating the need for EBP, and the resident herself was unaware of the reason for the precautions. For the second resident, who had a surgical wound on his right lower leg requiring daily dressing changes, staff wore gloves but not gowns during care, and PPE was not accessible at the room entrance. The care plan for this resident specified that both gloves and gowns should be used for high-contact activities, but this was not consistently followed. Further observations in the therapy area showed that staff did not use PPE when providing direct care, such as assisting with transfers and mobility, to residents on EBP. Interviews with therapy and nursing staff revealed gaps in knowledge regarding when and where PPE should be used, particularly outside of resident rooms. The facility's policy required EBP, including gown and glove use, during high-contact activities both in resident rooms and in shared areas like the therapy gym, but this was not adhered to in practice.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as outlined in its own policy. The Director of Nursing (DON), who also served as the infection preventionist, acknowledged that the facility was not consistently using the SBAR form based on McGeer criteria for infection surveillance, particularly for suspected urinary tract infections (UTIs). The DON admitted that staff often bypassed the required documentation of symptoms before contacting physicians, and the facility was almost always noncompliant with this process. Additionally, the DON did not monitor infections by resident location to identify potential clusters and only reviewed monthly antibiotic use reports from the contracted pharmacy, which lacked information on diagnosis or appropriateness of antibiotic use. Further review revealed that the facility did not adhere to several key components of its antibiotic stewardship policy. The DON did not complete an annual summary of antibiotic use, failed to hold antibiotic stewardship meetings, did not perform random audits of antibiotic prescriptions, and did not track at least one outcome measure associated with antibiotic use monthly. The facility also lacked an antibiogram, which is required to guide antibiotic use protocols, and did not provide annual feedback to prescribing physicians regarding their antibiotic use for residents. Documentation related to the stewardship program, such as meeting minutes and feedback reports, was not maintained as required by policy. The DON was unaware that the facility's infection rate for UTIs among long-stay residents was above state and national averages, as reported in the facility's quality measures. The facility's policies required the infection preventionist to report findings of surveillance activities, including infection rates and types, to the QAA committee, physicians, and other staff, but these activities were not being carried out as described. The facility's own assessment claimed that infections were tracked and trended, and that there were regular meetings to discuss infection control and antibiotic stewardship, but these practices were not substantiated by the DON's statements or by documentation.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that the designated infection preventionist, who was the Director of Nursing (DON), had completed the required specialized training in infection prevention and control. The DON was hired in October 2021 and began the CDC's Nursing Home Infection Preventionist Training course in October 2022. However, as of the time of the survey, the DON had only completed 5 out of the 23 required modules and was not aware that the course was incomplete. Record review confirmed the lack of a certificate of completion for the full course, and the DON acknowledged not having finished the training.
Deficient Infection Control and Documentation for Respiratory Devices
Penalty
Summary
Surveyors identified deficiencies in the facility's provision of safe and appropriate respiratory care for residents requiring respiratory devices, specifically related to infection control practices and documentation. For one resident using a nebulizer, the device was observed stored on the floor and the mask was hung on a tack between uses. The resident reported not cleaning the mask after treatments, and there was no documentation in the electronic medical record (EMR) regarding cleaning frequency, responsibility, or method. The facility's policy required cleaning after each use, but this was not consistently followed or documented. Another resident using a CPAP machine did not have a current physician's order for its use, and neither the initial nor current care plan addressed the CPAP or the resident's respiratory diagnoses. The resident reported that while nurses refilled the CPAP reservoir, the mask and tubing had not been cleaned since admission. There was also no documentation in the EMR regarding cleaning of the CPAP equipment, despite facility policy requiring weekly cleaning and documentation in the medication administration record (MAR). Interviews with staff, including an LPN and the DON, revealed inconsistencies in knowledge and practice regarding cleaning and documentation of respiratory devices. The DON was unaware of the lack of physician order, care plan documentation, and cleaning records for the CPAP. Additionally, facility policies related to cleaning and storage of respiratory equipment were found to be inconsistent and not always reflective of actual practices, contributing to the deficiencies observed.
Failure to Assess and Address Trauma-Informed Care Needs for Residents with PTSD
Penalty
Summary
The provider failed to assess and address the trauma-related needs of two residents diagnosed with post-traumatic stress disorder (PTSD). Both residents had moderate cognitive impairment and complex psychiatric histories, including anxiety, depression, hallucinations, and a history of chemical dependency. Despite these diagnoses, their care plans did not include specific interventions, triggers, or behavioral supports related to their PTSD or associated mental health conditions. One resident, a military veteran, had a documented incident where he struck another resident after being disturbed in his room, yet his care plan lacked any trauma-informed strategies or behavioral interventions. Additionally, there was no evidence that either resident was receiving scheduled or as-needed mental health services as indicated in their care plans. Interviews with facility staff, including the DON and LPNs, revealed that there was no policy or formal assessment process for trauma-informed care in place. Staff acknowledged that while trauma was noted at admission, there was no documentation or follow-up assessment, and interventions for PTSD were not identified or implemented in the care plans. The facility's own policy referenced the need to identify and implement interventions for residents with trauma or psychiatric diagnoses, but this was not reflected in practice. No trauma-informed care policy was provided when requested by surveyors.
Failure to Date Opened Food and Remove Expired Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food safety practices within the facility's kitchen. In the dry food storage room, there were opened containers of cereal that were not dated when opened. In the walk-in refrigerator, a carton of supplement and a package of shredded mozzarella cheese were found past their use-by and best-by dates, respectively. The mozzarella cheese had also physically deteriorated, condensing into quarter-sized balls. These observations indicate that food items were not consistently dated upon opening and expired items were not removed from inventory as required. During an interview, the dietary manager was unaware of the unmarked and outdated food items. He stated that it was his expectation for staff to date containers when opened and to use or discard food before expiration. The facility's policies require regular inspection of food products, proper labeling and dating of opened items, and adherence to FIFO (First In First Out) procedures. However, these policies were not followed, resulting in the presence of undated and expired food in storage areas.
Failure to Supervise Medication Administration Leads to Resident Self-Harm
Penalty
Summary
The facility failed to ensure the safety of a resident by not observing her take her medications, which led to the resident hiding and later ingesting multiple doses of Tylenol as an act of self-harm. The resident, who was cognitively intact with a BIMS score of 15, had a history of depression, anxiety, bipolar disorder, and other health issues. Despite her mental health conditions and the absence of an order for self-administration of medications, staff left her Tylenol on her bedside table without supervision, allowing her to accumulate and hide the medication in her room. The resident was later hospitalized for hypotension and liver failure, where she disclosed to hospital staff that she had ingested several Tylenol tablets in an attempt to end her life. Interviews with staff revealed that the resident had been isolating herself, refusing meals, and showing signs of severe depression. The Director of Nursing acknowledged that the staff had failed to supervise the resident adequately during medication administration, which was against the facility's policy that required staff to remain with residents until medications were swallowed.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The provider failed to adhere to their medication administration policy, resulting in a significant medication error involving a resident who required hospitalization. The resident, who was cognitively intact with a BIMS score of 15, had a history of depression, anxiety, bipolar disorder, and other medical conditions. Despite not having an order to self-administer medications, the resident was able to accumulate Tylenol tablets by hiding them in a plastic container in her dresser drawer. This occurred because the nursing staff left her medication on the bedside table and did not ensure she consumed it, contrary to the facility's policy that required staff to remain with residents until medications were swallowed. The incident came to light after the resident was hospitalized for hypotension and liver failure, following her admission that she had ingested several Tylenol tablets in a self-harm attempt. Interviews with staff revealed a lack of awareness and adherence to proper medication administration procedures, as well as insufficient education and monitoring following the incident. The director of nursing acknowledged the failure in staff oversight and the need for future audits, but no audits or monitoring had been conducted since the incident. The facility's policy clearly stated that medications should not be left with residents without orders and documentation for self-administration, which was not followed in this case.
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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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