Citations in South Dakota
Statistics, citations and compliance trends for long-term care facilities in South Dakota.
Statistics for South Dakota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in South Dakota
Delayed Response to Resident Call Lights: Staff did not respond promptly to call lights for multiple residents, with logs showing repeated waits over 20, 30, and even 50 minutes, and some residents reporting waits up to 2 hours. Several residents said they became incontinent while waiting for bathroom help, and one resident was observed unable to reach her call light because it was disconnected from the extender. Residents also reported call lights left out of reach and concerns that staff were not available on the floor.
Expired hand sanitizer was found in many resident rooms, a linen cupboard lacked a covering to protect linens from airborne infectants, and a resident’s wheelchair had torn, dirty padding. Staff also failed to consistently follow EBP and hand hygiene during personal hygiene and wound care for residents with pressure ulcers, including not cleansing a wound before dressing it and bringing wound care supplies into multiple rooms without sanitizing equipment between residents.
Inaccurate MDS coding was found for two residents whose diabetes meds were non-insulin injectables. One resident with ESRD and diabetes had Ozempic ordered, and another resident with CKD and diabetes had Mounjaro ordered, but both MDS assessments incorrectly coded insulin use and hypoglycemic drug class use. The MDS coordinator acknowledged the coding error but did not update the assessments after learning of the inaccuracy.
Improper Storage and Dating of Oxygen and CPAP Equipment: Two residents had oxygen equipment and CPAP items observed out of proper storage, including nasal cannula tubing on the floor, undated or empty humidifiers, and a CPAP mask on the floor. One resident had OSA with an order for oxygen at bedtime and as needed, and the other had COPD with orders for nightly CPAP and continuous oxygen. Staff stated the tubing, humidifier, and CPAP mask should be stored and dated per facility practice, and the facility policy required weekly changes and dating of oxygen equipment.
Improper Hand Hygiene During Food Prep: A cook wore gloves while handling cucumbers, touched a garbage can lid, and then continued handling food without removing the gloves or washing her hands. She later changed gloves and resumed cutting cucumbers, then removed the gloves and washed her hands. The DM and the cook both stated hand hygiene was expected before gloving and after glove removal.
Nonfunctioning Resident Call Lights: A resident reported waiting a long time for staff to answer her call light and said it had been disconnected from the wall extender, while another resident said her call light had been unplugged and she had to get help by having a friend use his call light. Staff and residents also reported repeated call light problems for another resident, and the DON stated call lights were expected to always be in working order; the facility did not have a call light policy.
Delayed Response to Resident Call Lights
Penalty
Summary
The provider failed to ensure staff responded promptly to resident call lights for 11 of 16 sampled residents, including residents 6, 22, 30, 34, 36, 40, 41, 62, 64, 68, and 73. Multiple residents reported waiting extended periods for assistance after activating their call lights, with some describing waits of 15 minutes to 2 hours. Several residents stated that delayed responses affected their ability to get help with bathroom needs, personal care, repositioning, and transfers, and some reported becoming incontinent while waiting for staff. Resident interviews and call light logs showed repeated long response times. Resident 6 reported waits of 15 minutes to 2 hours, and his call light log documented waits over 20, 30, and 40 minutes. Resident 30 reported sometimes waiting a long time, and her log showed multiple waits over 20 and 30 minutes. Resident 64 reported long waits, including a 2-hour delay during shift change, and stated she became incontinent of urine when staff did not respond promptly; her log showed multiple waits over 20 and 30 minutes. Resident 34 reported long waits that led to incontinence and said staff sometimes did not give her the call light device; her log showed repeated waits over 20, 30, and 40 minutes. Resident 36 reported waiting 20 to 45 minutes for help, and his log showed 29 response times over 20 minutes, including 11 over 30 minutes. Resident 40 and her family member reported that she sometimes lost bladder control while waiting for bathroom assistance, and her log showed multiple waits over 20, 30, and 50 minutes. Additional observations showed call lights were sometimes not within residents’ reach or were not functioning. Resident 34 was observed unable to reach her call light, and staff later found it disconnected from the extender. Staff interviews confirmed that call lights were sometimes found out of reach. During the resident council meeting, residents reported long waits, call lights left out of reach, and concerns that staff were not on the floor because they were in the breakroom or smoking. Staff interviews reflected differing expectations for response times, ranging from 2 minutes to 15 minutes, and the DON and executive director acknowledged that response times were sometimes delayed, including when staff had to locate a lift or when call lights were turned off before needs were addressed. The facility did not have a call light policy.
Infection Control Failures in Resident Care and Environmental Practices
Penalty
Summary
The provider failed to ensure infection prevention and control practices were followed in multiple areas of resident care and the environment. Surveyors observed expired hand sanitizer dispensers in 29 of 64 resident rooms, and the DON confirmed the facility did not have a specific policy for expired hand sanitizer products and was not sure who monitored expiration dates. The ED also confirmed the sanitizer was expired in those resident rooms and stated staff were not assigned to check expiration dates because it should not last that long in the rooms. Surveyors also observed a linen cupboard outside the TCU dining room that contained blankets, sheets, bath blankets, and gowns but had no doors or covering to protect the linens from airborne infectants. Staff interviewed stated they would not consider the linens in that cupboard to be clean. In addition, resident 26’s electric wheelchair had torn and partially missing padding on the right handle, with scotch tape wrapped around the damaged area. The resident stated the padding was not comfortable and that he had complained but staff did not address his concerns. Multiple observations showed staff did not consistently follow enhanced barrier precautions and hand hygiene during personal hygiene and wound care for residents with pressure ulcers. For resident 34, CNAs and a CMA provided hygiene care and wound care without consistent gown use, hand hygiene, or wound cleansing before dressing application. RN W applied a dressing without cleansing the wound first and stated the CNAs had already cleaned it, although she agreed that was not what was on the treatment plan. For residents 5, 6, 9, 10, and 34, the ADON/LPN/IP and RN U brought wound care supplies into multiple rooms, used the same bottles of soap, saline, betadine, and other items across residents, failed to sanitize wound care equipment between uses, and did not always perform hand hygiene appropriately. The report also noted that the facility’s infection surveillance report showed multiple healthcare-associated infections, and the facility policies required hand hygiene, EBP for residents with wounds, and routine surveillance of compliance with protective clothing and equipment.
Inaccurate MDS Coding for Diabetes Medications
Penalty
Summary
The facility failed to ensure accurate MDS coding for dialysis-related medications for two residents. Resident 4 had diagnoses including type 2 diabetes mellitus without complications, end stage renal disease, and dependence on renal dialysis. His EMR showed an order for Ozempic (semaglutide) 0.25 mg subcutaneously once weekly for diabetes, but his annual MDS coded section N0350 as insulin injections in the last seven days as yes and section N0415J hypoglycemic (including insulin) as yes. Resident 59 had diagnoses of chronic kidney disease and type 2 diabetes mellitus without complications. Her EMR showed an order for Mounjaro (tirzepatide) 2.5 mg subcutaneously once weekly for diabetes, but her quarterly MDS coded section N0350 as one insulin injection in the last seven days and section N0415J hypoglycemic (including insulin) as yes. The MDS coordinator stated she knew Ozempic and Mounjaro were coded inaccurately as insulin and learned of the inaccuracy on 4/24/26, but did not update the MDS assessments for residents 4 and 59.
Improper Storage and Dating of Oxygen and CPAP Equipment
Penalty
Summary
The provider failed to ensure infection control practices were followed for oxygen equipment for two residents. One resident had obstructive sleep apnea and an order for oxygen at 3 L by nasal cannula at bedtime and as needed; observations showed the nasal cannula tubing on the floor and not dated, and the pre-filled humidifier was not dated. The resident’s June 2026 TAR did not indicate when the nurse was to change the oxygen tubing. Another resident had COPD and orders for nightly CPAP use and continuous oxygen at 2 L. Observations showed the oxygen concentrator in the room, the nasal cannula tubing dated but later found on the floor, the pre-filled humidifier empty and not dated, and the CPAP mask on the floor between the bed and nightstand. Staff interviews stated the oxygen tubing should be stored in a bag or in the bedside table drawer when not in use, the CPAP mask should be stored on the CPAP machine, and the tubing and humidifier should be dated when changed. The facility policies stated oxygen tubing and nasal cannula/mask were to be changed weekly, the tubing should be changed when found lying on the floor, and the humidifier bottle should be replaced weekly and as needed with date and initials.
Improper Hand Hygiene During Food Preparation
Penalty
Summary
Food was not handled in accordance with standard food safety practices during kitchen food preparation. During observation, cook Y wore gloves while peeling cucumbers, then walked to the garbage can, lifted the lid, and discarded the peelings. With the same gloved hands, she placed the peeled cucumbers in a bowl and rinsed them with water. She then removed her gloves and did not wash her hands before continuing food handling tasks. Cook Y later placed a bag of shredded cheese in the walk-in cooler, used pot holders to remove a peach cobbler pan from the oven, and then changed tasks by taking a dirty knife to the dirty dish area and obtaining a clean knife. She put on a new pair of gloves and cut the cucumbers on a cutting board, then picked up the cut cucumbers and placed them in a bowl. She brought the dirty knife and cutting board to the dirty dish area, wiped the counter with a sanitizer cloth, removed her gloves, discarded them in the trash can, and washed her hands with soap and water. In interview, cook Y stated she should wash her hands with soap and water when entering the kitchen, before putting on gloves, and after removing gloves, and the dietary manager stated she expected cook Y to remove her gloves after touching the garbage can lid and wash her hands after glove removal.
Nonfunctioning Resident Call Lights
Penalty
Summary
The provider failed to ensure that resident call lights were functioning for three sampled residents whose call lights were not working. Resident 34 was observed in bed and stated she had waited a long time for staff to answer her call light and then would be incontinent of urine. She said she had turned her call light on a while ago and no one had come. When RN P checked, resident 34’s call light was found disconnected from the call light extender that plugged into the wall, so it did not turn on when pushed. Resident 34’s EMR showed a BIMS score of 14, indicating intact cognition. Resident 73 stated she had problems with her call light being unplugged from the wall and had to yell to a friend across the hall to turn on his call light to get staff help. Her EMR showed a BIMS score of 15, indicating intact cognition. During the Resident Council Meeting, staff and residents reported that resident 41’s call light had not worked numerous times and that resident 73 had issues with her call light not working. On another observation, resident 34’s call light turned back off on its own, and the ADON/LPN/IP stated that it did that sometimes. RN P also stated that call lights sometimes get hooked under the bed and pulled out of the connector, causing them not to work. The DON stated she expected call lights to always be in working order, and the facility did not have a call light policy.
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Compliance trends in South Dakota
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in South Dakota
- The Dietary Manager educated all dietary staff on proper sink usage, water temperatures, sanitizer temperatures, and the importance of correct documentation and corrective actions when temperatures are outside requirements. ServSafe certification was pursued for key staff members, and new logs were implemented to ensure compliance with sanitation standards (L - F0812 - SD) .
- All expired test strips were removed, and new, non-expired strips were placed for use. Disposable dining ware was used temporarily until the dishwasher was functioning correctly. Staff received education on procedures for a non-working dishwasher and the importance of using non-expired test strips. Monitoring systems were established to track the expiration dates of test strips and ensure ongoing compliance (J - F0812 - SD) .
- Dietary staff were instructed to use paper plates and to wash all non-disposable items in the three-compartment sink until the dishwasher was repaired. A booster water heater was arranged to be installed to achieve the required dishwasher temperatures. New policies and temperature charts were implemented, and staff received mandatory education on the updated procedures (J - F0812 - SD) .
Failure to Maintain Proper Water Temperatures in Kitchen
Penalty
Summary
The provider failed to maintain the required water temperatures in the three-compartment sink in the kitchen, which increased the potential risk of foodborne illnesses for the residents. Observations revealed that the wash water temperature was consistently documented as 90 degrees Fahrenheit or lower, contrary to the required 110 degrees Fahrenheit. Additionally, the sanitizer water temperature was not maintained at the required 75 degrees Fahrenheit. Interviews with kitchen staff, including a cook and the dietary supervisor, indicated a lack of awareness and understanding of the correct temperature requirements. The dietary supervisor admitted to not knowing the expected wash water temperature and only reviewed logs to ensure documentation was completed, not to verify if the data was within expected parameters. A review of the August 2024 Three-Compartment Sink Log showed discrepancies, with wash water temperatures either exceedingly high or low, and no wash water temperatures documented for the entire month. The sanitizer water temperature was often recorded in the wrong column, and many recorded PPMs were below the expected range. The deficiency was identified as an immediate jeopardy situation, requiring immediate corrective action. The provider's failure to adhere to the Food and Drug Administration's recommendations and their own policy for maintaining proper water temperatures in the kitchen's three-compartment sink posed a significant risk to the health and safety of the residents receiving meals prepared in the facility.
Removal Plan
- DM educated all dietary staff on the 3 sink method, 3 compartment sink order, 3 compartment sink steps, water temperature in a 3 compartment sink, sanitizer temp, and when it is essential to clean and sanitize a utensil, sanitizer per manufacturer recommendations that include submerging for at least 1 minute.
- Education to dietary staff on compartment sink log requirements of testing temps and sanitizer ppm, including action required if temps are not within the requirements.
- DM, primary dayshift cook, primary evening cook, are enrolled in ServSafe Certification.
- All new dietary staff will receive ServSafe certification.
- A new log was created by DM to record wash, rinse, sanitizer water temperatures, and sanitizer ppm with each use, including what to do if temps or ppm are outside of parameters.
- LNHA provided education to DM on the policy and procedure manual, including 3 compartment sink method regulations, job description of the dietary manager including adherence to policies and ensure that sanitary regulations are followed by the entire department.
- Education provided on supervisory roles including ensuring the department adheres to State and Federal regulations, and assuming the authority, responsibility and accountability to carry out the duties of the dietary department, monitor use of equipment and chemicals, and ensuring required documentation is completed and appropriate per regulations.
- Education included reporting to LNHA any areas of concern within the dietary department, equipment, and chemicals.
- Dietary manager will complete ServSafe certification.
Inadequate COVID-19 Management and Infection Control
Penalty
Summary
The facility failed to manage COVID-19 cases effectively among 12 sampled residents, leading to improper precautions and further transmission of the disease. Observations revealed that residents who tested positive for COVID-19 were not isolated properly, with some negative residents remaining in the same room as their positive roommates. Staff were observed not following proper protocols for personal protective equipment (PPE) usage, such as not performing hand hygiene before and after glove use, and not changing N95 masks between rooms. Additionally, there were instances where staff did not wear PPE correctly, such as not securing N95 masks properly or wearing gowns outside of isolation rooms. The facility's records showed a lack of documentation regarding informing residents or their responsible parties about the risks of staying in the same room with COVID-19-positive roommates. Interviews with the Director of Nursing (DON) indicated that while there was an expectation to inform residents and document such communications, this was not consistently done. The facility's COVID-19 outbreak policy required placing residents with confirmed infections in single-person rooms when possible, but this was not adhered to, as evidenced by multiple residents remaining in shared rooms despite positive test results. Further deficiencies were noted in the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and wounds. Observations showed that staff did not consistently use gowns, gloves, or eye protection when providing care to these residents, contrary to the facility's policy. Interviews with staff revealed a lack of awareness and adherence to EBP protocols, with some staff unable to locate necessary PPE or unaware of the requirements for its use. This lack of compliance with infection control measures contributed to the facility's failure to prevent the spread of infections effectively.
Removal Plan
- All COVID-positive residents were moved in with other COVID-positive residents. All negative residents are grouped with well residents with no signs or symptoms of COVID. Other negative residents with known exposure, including resident #6, #38, and resident #8, are in the presumptive area with other presumptive residents.
- Staff have been educated on the importance of keeping all positive residents on isolation for 10 days. Staff are to redirect if they want to come out of their room.
- Staff education was completed by the DON and RN Nurse Specialist to ensure all staff who are currently working and are providing care to positive and presumptive residents knew how to properly DONN and DOFF PPE. PPE is put on prior to entering positive and presumptive rooms. This includes removing the gloves and gown inside the room and performing hand hygiene. The removal of the eye protection and mask happens outside the room. Masks and eye protection are discarded. Hand hygiene is performed again. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on properly wearing an N95 mask. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on proper hand hygiene after DOFFING PPE prior to assisting another resident. All those not on shift will be educated prior to them coming on shift.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Deficiency in Diabetic Care and Physician Notification
Penalty
Summary
The provider failed to ensure proper care and services for diabetic residents, specifically in monitoring blood sugar levels and notifying physicians when levels were outside the normal range. This deficiency affected four out of seven diabetic residents, leading to instances where blood sugar levels were not managed according to accepted clinical standards. Interviews and record reviews revealed that interventions and timely follow-ups were inconsistently documented, contributing to the deficiency. Resident 38, who has type 1 diabetes mellitus and other health conditions, experienced fluctuating blood sugar levels. On multiple occasions, her blood sugar dropped to dangerously low levels, yet there was no documentation of interventions or physician notifications. Similarly, resident 22, with type 2 diabetes and other serious health issues, had several high blood sugar readings without any record of physician notification. Resident 3, also with type 2 diabetes, had high blood sugar levels recorded without any documented physician contact. Resident 20, who is severely cognitively impaired, had high blood sugar levels without physician notification as well. The facility lacked a written policy on hypoglycemia management or diabetic care, relying instead on standing orders that were not reviewed by the current DON. Interviews with staff, including the ADON, revealed inconsistencies in the process for managing low or high blood sugar levels, with some staff unsure of the facility's policy. The deficiency was further highlighted by the lack of documentation of physician notifications for numerous blood sugar readings outside the normal range.
Removal Plan
- Diabetic residents #3, #20, #22, and #38 who receive insulin will be managed with the glycemic management protocol given by the medical directors' guidelines.
- Nurses (RN and LPN) as well as medication aides have been educated on hypoglycemia and hyperglycemia protocols.
- Nurses are to contact each individual residents' provider in event of a low or high blood sugar reading.
- Nurses were educated to document interventions for low or high blood sugar within the resident's EMR.
- Nurses have been educated on the importance of following each individual resident's guidelines given by the resident's medical provider to properly manage diabetes.
- Nursing staff education was completed by the DON and ADON to ensure those who are currently working are providing appropriate glycemic care and the steps to follow in the event of a low or high blood sugar reading.
- Glycemic management protocol instructs that the nurse on duty will contact the residents' provider during clinical hours or their hospital on-call provider after business hours.
- All nurses and medication aides not on shift will be educated prior to them coming on shift.
- All nurses and medications aides were educated on glycemic management protocols.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Failure to Ensure Proper Sanitation Levels in Kitchen
Penalty
Summary
The provider failed to ensure that staff were able to verify the chemical sanitation level required to sanitize the dishes used for preparation and serving residents' food. This deficiency was identified through observations, interviews, and record reviews. The survey revealed that the dishwasher's chemical sanitation was not functioning, and staff were not aware of any process to follow when this occurred. Additionally, staff could not accurately verify the chemical sanitation level of the dishwasher due to the use of expired test strips. During the survey, it was observed that the sanitizing testing strips located by the three-compartment sink had expired. Interviews with dietary staff confirmed that these expired strips were being used to test the sanitizing solution, which was not at the correct parts per million (PPM) for effective sanitization. The Nutrition and Food Services Supervisor confirmed that the test strips were outdated and that there were no other test strips available for use. Furthermore, the dishwasher sanitizer was tested and found to be insufficient, with a reading of 10 ppm instead of the required 50 ppm. The deficiency was further compounded by the lack of awareness among staff regarding the expiration of test strips and the proper procedures to follow when the dishwasher was not functioning correctly. The provider's policies and procedures for sanitizing food contact surfaces and warewashing were not effectively implemented, as evidenced by the expired test strips and the inadequate sanitizing solution levels. This failure increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen and served to the residents.
Removal Plan
- Provide dishwasher manufacturer manual and disinfectant information to support instructions are being followed and appropriate sanitation is occurring.
- Use disposable paper plates, cups, and silverware until dishwasher is running appropriately.
- Place new non-expired strips in for the 3 comp sink.
- Remove all expired strips in kitchen.
- Wash all dishes in the 3-comp sink until dishwasher is fixed to verify levels.
- Implement the use of a Monitoring Use of Ecolab disinfectant Test Strips form for staff to sign off on expiration date of a cartridge when replaced and label in the cartridge holder on the wall.
- Complete education with all dietary staff on proper procedure for non-working dishwasher and education on non-expired test strips with return demonstration.
- Educate all staff via PCC Communications that kitchen staff must ensure all chemical test strips are not expired for the dishwasher and the 3 comp sink.
- Add to the TELS Service Provider a task for Director of Environmental Services to monitor weekly if a cartridge is near expiration and needs replacement.
- Contact EcoLab to fix dishwasher. In the meantime, try a new bucket of Ultra San Ecolab 5 gallon liquid sanitizer in the dishwasher and retest.
Dishwasher Temperature Noncompliance
Penalty
Summary
The provider failed to maintain the dishwasher wash cycle temperature at a minimum of 120 degrees Fahrenheit as required by the manufacturer's manual. Observations and interviews revealed that the dishwasher's wash cycle temperatures were consistently below the required threshold, with recorded temperatures ranging from 100 to 115 degrees Fahrenheit over several days. There were also numerous instances where wash, rinse, and chemical sanitation level checks were missing. The facility's dishwasher was serviced monthly by a vendor, but the issue persisted, and the administrator was not notified of the low-temperature readings. Interviews with dietary staff confirmed that the dishwasher's external thermometer readings matched those of a thermometer run through the dishwasher, both indicating temperatures below the required 120 degrees Fahrenheit. The dietary aide acknowledged that the wash temperature should be 120 degrees Fahrenheit. Despite the lack of gastrointestinal illness reported in the past three months, the administrator expected staff to report low-temperature readings, which did not occur. A review of the ECOLAB service report and the facility's cleaning policy revealed discrepancies in temperature requirements. The ECOLAB report noted a wash temperature of 100 degrees Fahrenheit and advised monitoring for compliance. The facility's policy inaccurately stated that the dishwasher, a chemical sanitizing machine, required temperatures between 90 and 110 degrees Fahrenheit, conflicting with the manufacturer's specification of a minimum of 120 degrees Fahrenheit.
Removal Plan
- Dietary staff were instructed to use paper plates and bowls and to use the three-compartment sink for cleaning and sanitizing of all utensils/pots/pans, etc. that are not disposable.
- Administrator met with Dietary staff and reviewed the policy and procedure on the use of the three-compartment sink as well as instructions located above the three-sink area.
- Administrator spoke with the representative from ECO Lab concerning this noncompliance. Recommendation to install a booster water heater to the current dishwasher unit.
- Administrator spoke with [Name] from [Name] Heating and Cooling and arranged for a service call to complete wiring for the installation of the booster water heater.
- [Name] Heating and Cooling presented to facility. Conversation was held with [Name] from [Name] Heating and Cooling and [Name] from ECO Lab via phone. [Name] from ECO Lab and [Name] from [Name] Heating and Cooling will be installing the booster water heater.
- Administrator completed and implemented new Dishwasher Temperature Policy and Low-Temperature Dishwasher Chart.
- Dietary Staff mandatory education will be held to review the Dishwasher Temperature Policy and Procedure as well as the Low-Temperature Dishwasher Chart.
- Daily audits to ensure compliance with the dishwasher temperature will be completed by this Administrator and will report findings to the QAPI Committee. Following continuous compliance, daily audits will change to weekly audits. The continuation of audits will be reviewed monthly during QAPI Committee meetings.
Inadequate Supervision Leads to Resident Self-Harm
Penalty
Summary
The provider failed to provide adequate supervision for a resident to prevent actions of self-harm. The resident was observed in his room with multiple open areas on his bilateral lower legs, some of which were actively bleeding, while holding a sharp instrument. Staff interviews revealed that they were aware the resident had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. The resident's care plan allowed him to have sharps in his possession to remove perceived bugs from his skin. The resident had a history of picking at his skin and cutting himself, believing there were bugs under his skin. He had been seen by a behavioral counselor due to suicidal ideations and hallucinations. Despite this, the resident was allowed to keep sharps in his room, and staff were aware of his behavior but did not adequately supervise or intervene to prevent self-harm. Interviews with staff indicated that the resident was independent, allowed to leave the premises, and would purchase items, including sharps, from a store. The resident's care plan documented his behavioral symptoms, including cutting and picking at his skin, and allowed him to keep sharps in his room. The care plan noted that the resident declined to follow physician-recommended advice and would not allow nurses to care for his open areas. Staff were aware of the resident's behavior and the presence of sharps in his room, but there was no inventory or tracking of the sharps, and the resident's wounds were not regularly documented or treated by nursing staff.
Removal Plan
- All sharps have been removed from Resident 20's room.
- Psychiatry, primary care provider and counselor have been notified for guidance in managing any adverse behavioral changes.
- Resident 20 has been re-educated on hand hygiene, sharps in his room, infection prevention to include covering wounds.
- Updates to the care plan include removing sharps, offering tubi-grips for arms and lower legs for covering of wounds when leaving his room, handwashing education, wound assessment completed, one-hour check while in the facility for behaviors given resident psychiatric history then re-evaluate.
- Center of Excellence for Behavioral Health in Nursing Facilities contacted with expected response.
- Director of nursing spoke to Resident 20 about dressing changes.
- Resident agreed to let nursing staff change dressing twice a day.
- Nursing staff will monitor for any signs of infection during dressing changes and notify the physician if any noticed. These will be documented on Resident 20's treatment.
- Nursing will remove soiled towels and washcloths when in his room providing dressing changes. This has been included in the treatment plan and added to the certified nursing assistant (CNA) flowsheet.
- Resident was informed that he would not need to buy wound/dressing supplies.
- Sharps removed from resident 20's room.
- All other current resident rooms were checked for sharps and any of concern were removed.
- Discussed with Resident 20 that his bags would be checked upon return from shopping.
- Resident signed previous acknowledgment form that he agreed to staff removing sharps that he may bring back.
- Staff will conduct random room checks and will chart in Resident 20's chart as a treatment.
- This has been added to Resident 20's treatment plan and CNA flowsheet.
- Added a treatment order for nursing documentation for behavior/mood of resident 20.
- Resident 20's behavior documentation will be reviewed at interdisciplinary team (IDT) meetings and as needed with adjustments to care/treatment plan as warranted.
- Admission packet updated regarding review of sharps for safety.
- Resident 20's primary contacts have been re-educated on notifying staff prior to bringing/getting sharps items to resident via email.
- Resident 20 has been re-educated on proper hand hygiene for infection prevention and sharps.
- Staff have been re-educated on sharps in rooms and planned review of infection prevention practices related to transmission through OnShift.
- They receive this education annually at minimum.
- A skills fair reviewing infection prevention is scheduled and annually for staff.
- Sharps restriction added to admissions packet.
- Staff re-educated on infection prevention practices and safety of all residents related to sharps in resident rooms.
- Staff were educated through onshift message about the removal of sharps for any resident.
- Additional education provided to nursing staff related to resident 20 returning from shopping, the need to look in resident 20's bags for any sharp objects that staff would need to remove and secure in the medication room, staff will reiterate to resident that he is not able to have those items in his room.
- PRN treatment order added to check bags upon returning from shopping outings.
- Staff will also be educated on the random room checks that will be conducted on Resident 20's room for sharps found, those items will be removed and secured in the medication room.
- Treatment order added to document these random room checks for Resident 20, also added to CNA flowsheet to check room twice a day.
Resident Elopement and Fall Risk Management Deficiencies
Penalty
Summary
The report details a deficiency involving the elopement of a resident with severe cognitive impairment from a long-term care facility. The resident, who had a history of elopement and was assessed as a high risk for elopement, managed to leave the facility without staff knowledge. The resident was wearing a wander guard, a device intended to prevent such incidents, but there was no documentation of its functionality being checked as required. The elopement was not immediately detected, and the resident was found outside the facility and returned after a significant delay. Another deficiency involved a resident with cognitive impairment and a history of falls who was found on the floor, naked and covered in feces, after a call light went unanswered for an extended period. The resident had a history of falls and required assistance for all activities of daily living. Despite this, the call light system, which should have alerted staff to the resident's needs, was not responded to in a timely manner. The resident's care plan did not adequately address her high fall risk, and staff failed to anticipate her needs, leading to multiple falls. Interviews with staff revealed a lack of awareness and adherence to policies regarding resident safety and monitoring. Staff were not consistently checking the functionality of safety devices like wander guards, and there was a failure to respond to call lights promptly. The facility's policies on monitoring high-risk residents and ensuring their safety were not effectively implemented, contributing to the deficiencies observed.
Removal Plan
- A message was sent to all employees that summarized the education summary of elopement. This serves as the immediate education for all employees. If staff are not able to complete education, they will be required to complete the make-up prior to their next shift.
- RN S was educated on the process for calling DON/Administrator immediately when resident safety is at risk-including elopements. The nurse was also educated on the next step of the policy to initiate a head count of all residents when a door alarm is sounded with no explanation.
- Certified nursing assistant (CNA) T was noted to have missed a toileting round of resident 3. This would have decreased the time of the residents' elopement. The CNA T received a final corrective action for lack of rounding during this shift. This standard will be upheld for any employees that are found to have failed to complete their rounding as ordered/recommended.
- All staff were educated on the importance of rounding on all residents multiple times a shift. Residents with high fall and elopement to chart in the hallways so residents can be in eye site.
- All staff were educated on utilizing our call system as all exit doors are on the call system to notify all staff if an exit door is alarm on the scrolling screen and the radios.
- Assessment of resident was completed, and vital signs taken.
- An elopement drill was completed with day shift. Education was provided to staff involved with elopement.
- A potential elopement alert was initiated due to a phone call from someone in the community stating a resident was outdoors near [NAME] Road. Staff responded to code and facility did head count and everyone was accounted for.
- Hallway and department education is being completed with all staff regarding elopement processes and policy review. Elopement policy/procedure was reviewed, explained what an elopement is, who is considered an elopement risk, steps to take when a potential elopement occurs, who to notify if a resident does elope and how to respond to door alarms and completing head counts if no residents were found when alarm was responded to.
- Resident 3's physician was out to facility and updated again on recent elopement events. Resident 3's physician ordered lab work-up on him as this an increase in his normal behaviors. He also would like an update on how he is doing.
- Elopement Drills will be completed weekly x4. These will be completed on shifts, different days of the week and different locations within the building. Then every other week x 4 weeks.
Failure to Protect Residents from Abuse by Co-Resident
Penalty
Summary
The provider failed to protect two residents from abuse by another resident, leading to a deficiency. Resident 4 was observed inappropriately touching Resident 1, who has severe cognitive impairment due to dementia and psychosis, and Resident 2, who has dementia and amnesia. Both residents were unable to consent or defend themselves. Despite these incidents, the care plans for Residents 1 and 2 were not updated to reflect that they had been victims of inappropriate touching. Interviews with staff revealed that Resident 4 had a pattern of inappropriate behavior, including touching other residents' thighs and breasts. Staff members, including a registered nurse and certified nursing assistants, reported these incidents to the charge nurse and administration. However, the facility's response was inadequate, as the care plans for the affected residents were not updated, and there was a lack of immediate action to prevent further incidents. The facility's policy on abuse and neglect requires prompt investigation and reporting of such incidents, as well as immediate action to prevent further abuse. However, the facility did not adhere to these procedures, as evidenced by the lack of updated care plans and insufficient measures to protect the residents from further abuse by Resident 4. This failure to follow policy and ensure resident safety resulted in a deficiency being cited by the surveyors.
Removal Plan
- 30-minute checks on resident 4 initiated to ensure the safety of all residents.
- Medical director discontinued the use of Sildenafil and will monitor the use of other medications that could lead to sexual temptations.
- Resident 4 was scheduled to be evaluated by a psychiatry provider to rule out dementia or other medical conditions that could cause the more frequent sexual behaviors.
- Resident 4 was seen by a psychiatry provider.
- Care plans have been updated.
- Education was provided to all staff.
- Managers will provide the education to staff that were not in the building and staff will be required to receive the education before they start their next shift.
- All staff will continue to monitor behaviors and safety for all residents.
- Interventions in place will be assessed and will be modified if needed to make sure the issue is being resolved appropriately.
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