Citations in South Dakota
Comprehensive analysis of citations, statistics, 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
The facility failed to protect two cognitively impaired, elopement-risk residents from leaving the building without staff knowledge. One resident with dementia, agitation, and a roam alert was wandering and exit seeking at night; after a door alarm sounded, an RN moved to reset it, and the resident pushed through the south exit door and left the building unsupervised. Staff reported ongoing aggressive and exit-seeking behaviors, ineffective PRN anxiety medication, lack of training on managing such behaviors, and no participation in elopement drills, with close visual checks only started after the incident. A second resident on hospice with dementia, behavioral disturbances, and a roam alert was tearful, pacing, repeatedly packing to leave, and verbally expressing a desire to go; staff observed she had removed her window screens and were told to keep an eye on her, but no increased monitoring or PRN anxiolytics were used. She subsequently removed a window screen, pried the window open, crawled out, and was found by police several blocks away, demonstrating inadequate supervision and hazard control for residents at risk of elopement.
A resident with exit-seeking behaviors eloped from the facility on four separate occasions, including times when the resident slipped out as others entered, exited through an alarmed door, and was let out by an assisted living resident. Although the resident was quickly found and assessed without injury, the facility failed to conduct and document thorough investigations for most of these events. Key witnesses, including CNAs, family members, and the staff who found the resident, were not interviewed or asked to complete witness statements, and investigation records lacked basic details such as who discovered the resident. Interviews showed that the interim DON was unaware of existing witness statement forms, there was no formal investigation process in use, and required policy elements for incident investigations—such as interviewing all involved staff, residents, and families—were not followed.
A cognitively impaired resident with dementia and hearing loss, who frequently repeated requests and used the call light, was subjected to verbal abuse when a CNA allegedly told her to “shut the [expletive] up” in response to her calling out. A cognitively intact resident with an above-knee amputation, depression, and PTSD, whose room was across the hall, reported hearing the exchange and then seeing the CNA standing by the resident’s room, and multiple staff described this witness as reliable. Staff interviews further revealed that the CNA had appeared irritated and rude that shift, and an LPN reported a prior unreported incident in which the same CNA yelled at another resident. The facility’s abuse policy prohibits disparaging or derogatory language within a resident’s hearing, establishing that the resident was not protected from verbal abuse.
Two residents with significant symptoms did not receive timely completion of ordered diagnostic tests. For one resident with cirrhosis and acute kidney failure who reported painful urination, fever, and urinary urgency, a physician ordered a same‑day UA, but facility staff did not collect the sample as ordered; the resident was later evaluated at a clinic, found to have urinary retention, had a Foley catheter placed, and was treated for suspected UTI. For another resident with intracerebral hemorrhage who had dark black stools and strong‑smelling urine, the physician ordered CBC, CMP, and UA on the same day staff reported these symptoms, but the order was not acknowledged for several days, the CBC result was not available, the CMP had to be recollected, and the UA was delayed and ultimately not obtained after the physician later indicated it was unnecessary without additional symptoms. Staff and the DON acknowledged that physician orders were expected to be processed immediately and that these labs and UA should have been collected on the day the orders were received.
The facility failed to timely submit initial and final FRI reports to the SD DOH for multiple residents who experienced alleged abuse, falls with injury, seizures, head lacerations, and fractures. In several cases, initial reports were submitted many hours or days after serious events, exceeding the required 2‑hour or 24‑hour timeframes, and in numerous instances no final investigation report was ever submitted within the required 5 working days, despite state complaint records and rejections requesting completion. The administrator and DON, who were responsible for reporting and aware of the regulatory timeframes, acknowledged ongoing issues with incident reporting, while the facility’s own abuse reporting policy required immediate reporting of suspected abuse and timely submission of investigation results.
A cognitively intact resident reported that a CNA verbally and physically abused him during evening care, stating he was slapped, pushed onto the bed, and choked. The resident disclosed the alleged abuse to a CNA during a bath, who then informed the SSD, and the concern was brought to the IDT, but the administrator did not promptly follow up that same day. The resident repeated the allegation to an LPN/CC and later to a counselor, while assessments showed no visible injuries. Despite a written abuse policy requiring that all abuse allegations be reported to the state survey agency within 2 hours, the facility did not ensure that this allegation was reported within the required timeframe, resulting in a reporting deficiency.
A resident with dementia and severely impaired cognition, previously identified as at risk for elopement with care plan interventions requiring all exit doors to remain alarmed, was able to leave the facility through an east exit door after an LPN turned off the door alarm to allow entry for another resident and family and forgot to reactivate it. Later that evening, an RN could not locate the resident, prompting a search of the building and surrounding area. The resident was ultimately found by a citizen sitting on the ground across the street in very cold weather conditions, was returned to the facility cold to the touch with a low body temperature, and initially exhibited combative behaviors not typical for him before returning to baseline.
Non-compliance with F684 occurred when a resident was left without repositioning or continence care for about nine hours overnight due to an unupdated CNA assignment sheet and lack of hand-off communication during a split shift. Another resident, whose care plan required Cares in Pairs because of behavioral and safety concerns, was assisted with toileting by a single CNA, contrary to the documented intervention. In a separate event, a resident who activated a call light for incontinence care waited roughly one and a half to two hours before a CNA changed her brief, after the assigned CNA turned off the call light, returned to another room, and later dismissed reports of the resident hollering, leading another CNA to eventually provide the needed continence care.
Staff initiated and continued CPR on a resident with a documented DNR/DNI order, failing to verify and honor the resident's code status before and during resuscitation efforts. Despite code status information being available in the EMR and on hall sheets, staff performed CPR for about 20 minutes until the DON intervened and stopped the procedure after confirming the DNR status.
Two residents with cognitive impairments eloped from the facility by exiting through the front door without staff knowledge, after being mistaken for visitors and due to the door alarm system being bypassed with staff badges. Staff were not fully aware of which individuals were at risk for elopement, despite the presence of an elopement binder with photos and information, leading to inadequate supervision and failure to prevent accident hazards.
Failure to Prevent Elopement of Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for two residents identified as elopement risks, both of whom left the building without staff knowledge. The first resident had severe cognitive impairment with a BIMS score of 0 and diagnoses including unspecified dementia with agitation, depression, anxiety disorder, alcohol abuse in remission, ADHD, and insomnia. He had been assessed as at risk for elopement and wore a roam alert device. On the night of the incident, he was wandering, exit seeking, and exhibiting agitation and threats against staff. Despite these behaviors and his known history of aggression and exit seeking, he was able to push open a south exit door and leave the building at approximately 12:42 a.m. after the door alarm sounded and the RN moved toward the door to reset the alarm. The nurse reported she could not see him outside, immediately called 911, and did not send staff out to search due to concerns for staff safety and the dark conditions. The first resident’s behaviors had been ongoing, including exit seeking and aggressive actions toward staff, and he required significant one-to-one attention. Staff reported that PRN anxiety medication had been administered earlier in the evening but was ineffective, and attempts at distraction, food, and redirection were used. However, the RN stated she had never been trained by the facility to deal with that type of behavior, and both she and a CNA reported they had not participated in any elopement drills during their years of employment. The facility’s elopement policy existed, but education provided after the first elopement focused on assessment rather than on what to do during an actual elopement event. Fifteen-minute visual checks for this resident were not initiated until after the elopement occurred, despite his known elopement risk and severe cognitive impairment. The second resident also had severe cognitive impairment with a BIMS score of 3 and diagnoses including unspecified dementia with behavioral disturbances, anxiety disorder, diabetes, and a history of falls. She was on hospice at admission, identified as an elopement risk, and had a roam alert device applied. On the day of her elopement, she was tearful over her husband’s recent death, pacing the hallways, repeatedly packing her belongings to leave, verbalizing a desire to leave, and was visibly upset. Staff observed that she had removed the inner screens from her room windows and notified a clinical care leader, who instructed staff to keep an eye on her and stated that, without window cranks, she could not do anything further. No 15-minute visual checks were initiated by floor staff, and although she had PRN lorazepam orders, no PRN doses were documented as given that day. Later that evening, staff were notified by police that the second resident had left the building and was found approximately five blocks away. She had removed the screen from her window, pried the window open enough to crawl out, and exited the building without staff knowledge. At the time of her elopement, the outside temperature was about 24 degrees, and she was dressed in layered clothing with sandals and socks and had a blanket with her. The DON later stated that staff should have been concerned when the resident removed her window screens. Interviews revealed that while some nurses had received elopement education after the first resident’s elopement, there had been no further elopement education for staff following the second resident’s elopement, and the DON was unsure when the last elopement drill had been completed. These actions and inactions resulted in two residents at known risk for elopement leaving the facility without staff supervision.
Failure to Thoroughly Investigate and Document Multiple Resident Elopements
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document four elopement incidents involving one resident with exit-seeking behaviors. The resident left the building without staff knowledge on four separate occasions. During the first elopement, the resident exited when another family was entering the building and was outside for less than 10 minutes before staff were alerted by another resident’s family. Although staff witness statements from two CNAs were obtained, there was no documentation that the family who observed and reported the elopement was interviewed, and no additional investigation materials were present beyond what was in the facility reported intake. For the second elopement, the resident exited through a door that alarmed appropriately, and staff immediately returned the resident to the building after less than a minute outside. However, the report for this incident did not include any investigation actions such as obtaining witness statements from staff or family present at the time, nor evidence that other potential contributing factors, such as changes in mood or medications, were explored. During the third elopement, the resident was let out of the building by a resident from the attached assisted living center and was later found outside walking with another resident. The report did not specify which staff member found the resident, and no witness statements were gathered from staff or others present, including the CNA who saw the resident outside from her car and used her radio to notify staff, and another CNA who helped coax the resident back inside; both confirmed they were not interviewed and did not complete witness statements. During the fourth elopement, an LPN and a CNA responded to a front door alarm in the early morning hours, noted the resident’s room door open, and initiated a search. The CNA located the resident outside while the LPN was on the phone with emergency services, and the resident was assessed with no injuries and normal vital signs. Despite these events, the investigation records for this incident contained no witness statements from the involved staff. Interviews with the interim DON and administrator revealed there was no formal investigation form in use, the interim DON was unaware of existing witness statement forms, and investigations were being handled through progress notes and monitoring forms rather than a structured process. Facility policies on missing residents and abuse/neglect required detailed incident documentation and interviews of all involved staff, residents, and families, but the investigation team membership was not defined, and these policy expectations were not followed for the resident’s repeated elopements.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. A cognitively intact resident with a history of left leg above-knee amputation, depression, and post-traumatic stress disorder reported overhearing a male CNA tell another resident to “shut the [expletive] up” while responding to that resident’s repeated requests. The resident who was the target of the alleged verbal abuse had severe cognitive impairment with a BIMS score of 3, dementia, hearing loss, and chronic kidney disease stage 3, and was known to be impatient, verbally repetitive, and demanding of staff. On the evening in question, the cognitively intact resident was in her room across from the cognitively impaired resident’s room, heard the impaired resident repeatedly calling out and using her call light, and then heard a male voice respond with the profane directive. The cognitively intact resident wheeled herself to her doorway and observed the identified CNA standing by the cognitively impaired resident after hearing the profane statement. She later reported this to facility staff, stating she recognized the CNA’s voice and confirming his presence at the scene. The social worker interviewed both residents the following day; the cognitively impaired resident did not recall the incident and reported feeling fine, while the cognitively intact resident consistently described hearing the CNA tell the other resident to “shut the [expletive] up” and reiterated that the other resident had been calling out and demanding immediate help. Multiple staff, including the DON, LPN, and RN, described the cognitively intact resident as a reliable and truthful reporter. Additional staff interviews and record reviews supported concerns about the CNA’s interactions with residents. A CNA coworker reported that on the evening of the incident the CNA appeared irritated, overwhelmed, and in a bad mood, and that he had been rude to her, though she had not previously heard him swear at residents. An LPN reported having previously observed the same CNA yell at an exit-seeking resident and stated she had used that prior event as a teaching moment, but she had not reported it to management at the time. The facility’s abuse and neglect policy defines verbal abuse as the use of disparaging or derogatory language within a resident’s hearing, regardless of the resident’s ability to comprehend, and states that residents have the right to be free from verbal abuse by anyone. The incident as reported and corroborated by staff interviews demonstrates that the resident was subjected to verbal abuse in violation of this policy and resident rights.
Failure to Timely Complete Ordered UA and Lab Work for Two Symptomatic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and complete ordered diagnostic tests for two residents with concerning symptoms. For one resident with alcoholic cirrhosis, ascites, and acute kidney failure, the physician issued an order on 1/12/26 at 2:57 p.m. to collect a urine analysis (UA) sample and bring it to the clinic that day. Nursing documentation later that afternoon recorded the resident’s complaints of painful urination with sharp pain on attempting to void, increased frequency and urgency, a temperature of 101.1°F, pulse of 103, and pain rated 10/10. Despite these symptoms and the explicit same‑day order for a UA, the urine sample was not collected by facility staff on 1/12/26. On the following day, staff documented that the resident’s temperature had increased to 102°F and that the primary care provider requested the resident be seen at the clinic that day and to postpone scheduled GI testing. A late entry note indicated the provider, during in‑house rounds, recommended the resident be seen in the clinic due to fever and nausea. At the clinic, a bladder scan showed 906 cc of retained urine, a Foley catheter was inserted, a urine sample was obtained, IV antibiotics were administered, and oral antibiotics were ordered for a suspected UTI. The DON later confirmed there was no documentation of what information had been sent to the physician before the UA order on 1/12/26 and acknowledged that the UA should have been collected that day as ordered, and that not doing so may have caused a delay in treatment. LPN/CC F also stated the UA should have been collected on 1/12/26. The second resident had a diagnosis of intracerebral hemorrhage and a BIMS score indicating moderately intact cognition. Staff faxed the physician reporting dark black stools for two days and strong‑smelling urine. The physician responded with an order for CBC, CMP, and UA to be done that day, noting the resident was on iron, which could cause dark stools versus GI bleed. The order, faxed on 1/9/26, was not acknowledged in the record until 1/13/26. During this period, the physician emailed on 1/9/26 requesting a status update; LPN/CC F replied that the resident’s vital signs were stable, the resident felt fine, and staff had no further information. LPN/CC F later confirmed that the attached document to the physician’s email was the lab order and that the labs, including UA, should have been collected on 1/9/26 when the order was received. On 1/13/26, a progress note documented that the CNP had ordered CBC, CMP, and UA to be collected that day. LPN/CC F reported collecting the CBC and CMP at 11:31 a.m., but the CMP had to be recollected by the lab the next morning because the initial sample could not be tested. A subsequent note indicated that the day and evening shifts did not obtain a urine sample and that the resident was asleep, so the UA collection was rescheduled. On 1/14/26, the CMP was collected at 8:15 a.m., and LPN/CC F emailed the physician to review the labs; the physician replied that the labs were okay and later stated a UA was not needed unless the resident had symptoms other than odor. There was no CBC report available for review, and documentation showed the CMP was obtained by the clinic. The DON stated she was unsure when the lab order was received but expected labs to be collected the day the order was received if during lab hours. Staff interviews confirmed that physician orders were to be processed immediately and entered into the EMR the same shift they were received, and that resident 5’s labs, including UA, should have been collected on 1/9/26 when the order was received.
Failure to Timely Report Facility Incidents and Investigation Results to SD DOH
Penalty
Summary
The deficiency involves the facility’s failure to timely submit initial and final Facility Reported Incident (FRI) reports to the South Dakota Department of Health (SD DOH) for multiple residents who experienced reportable events, including alleged abuse, falls with injury, and other serious incidents. For one resident who reported an allegation of abuse on 1/3/26 at 6:00 p.m., the initial report was not submitted until 1/14/26 at 9:45 a.m., approximately 11 days after the event, and the final investigation report was submitted on 1/16/25, outside the required time frames. The SD DOH complaint record stated the facility failed to ensure timely reporting for this resident and that the delay failed to ensure immediate protection and oversight. The administrator acknowledged awareness of the required reporting time frames and responsibility for reporting but could not identify why the reports were not completed on time. The facility also failed to meet reporting requirements for several residents who had falls requiring further medical evaluation. One resident had a fall with a head laceration requiring staples on 12/28/25 at 9:45 p.m.; the initial report was not submitted until 12/29/25 at 8:37 p.m., exceeding the 2‑hour requirement, and the final report was not received until 1/20/26, beyond the 5 working‑day requirement. The SD DOH complaint record stated this failure placed the resident at risk for unaddressed abuse or neglect. The same resident had another fall with a head laceration on 1/4/26 at 2:28 p.m.; while the initial report was timely at 3:29 p.m., no final investigation report was ever submitted. Another resident had a fall on 10/13/25 at 4:18 p.m. with head and pelvic pain; the initial report was timely, but the SD DOH rejected the report twice requesting a final investigation, and no final report was submitted. The DON stated the final investigation report “got stuck in the cracks.” Additional residents experienced falls with injuries or serious symptoms for which the facility did not meet initial or final reporting requirements. One resident had a fall with a head laceration on 11/5/25 at 8:55 p.m.; the initial report was not submitted until 1:41 p.m. the next day, exceeding the 2‑hour requirement, and no final report was submitted despite SD DOH rejections and requests. Another resident had a fall with a seizure on 11/16/25 at 7:30 p.m.; the initial report was not received until 7:11 p.m. the following day, and no final investigation report was submitted. A different resident had a fall with head impact and seizure on 12/5/25 at 9:05 p.m.; the initial report was submitted the next day at 12:12 p.m., and the final report on 12/15/25, both beyond required time frames. One resident sustained a left arm fracture from a fall on 12/17/25 at 5:30 a.m.; the initial report was not received until 12/29/25 at 9:29 p.m., and no final report was submitted, with documentation showing inconsistent event dates. Another resident was involved in alleged potential resident‑to‑resident physical abuse on 11/21/25 at 7:00 a.m.; the initial report met the 24‑hour requirement, but no final investigation report was submitted. Interviews with the administrator and DON confirmed that they were responsible for completing initial and final FRI reports to the SD DOH and that they were aware of the state’s required time frames: allegations, falls of unknown origin, and falls with major injury to be reported within 2 hours, and all other incidents within 24 hours, with final investigation reports due within 5 working days. The administrator acknowledged the facility had issues with reporting FRIs and stated that staff were to call her or the DON at any time to inform them of incidents so they could determine reportability. She reported that all managers had completed education on reportable incidents, and about half of all staff had completed related education by the time of the survey. The facility’s Abuse Reporting and Response policy required immediate reporting of suspected or alleged abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source, and mandated reporting of investigation results to the state survey agency within 5 working days, but the documented events and complaint records showed repeated failures to follow these requirements for nine residents.
Failure to Timely Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required time frame after a cognitively intact resident reported being physically abused by a CNA. The resident, who had a BIMS score of 15 indicating intact cognition, alleged that on the evening of 1/3/26 a CNA verbally assaulted him, slapped him, pushed him into bed, and choked him during provision of care. A scheduled skin assessment on 1/5/26 documented no bruising or finger marks, and later assessment found no signs or symptoms of injury. The resident’s care plan noted a history of making accusatory statements about non-Caucasian staff and a preference for Caucasian staff, with a statement that all such reports would be taken seriously and investigated per policy. On the morning of 1/5/26, during the resident’s bath, he told a CNA that he had been physically abused by the CNA involved on 1/3/26. That CNA reported the allegation to the social services director the same morning. The social services director then reported the allegation to the interdisciplinary team meeting held that day and indicated that, after her report, the matter was to be handled by the administrator. Despite this, the administrator later acknowledged that she did not follow up with the resident on 1/5/26 when the allegation was reported, but instead waited until 1/6/26 to do so. Additional interviews further documented the resident’s repeated reports of the alleged abuse. On 1/8/26, while being checked on by an LPN/care coordinator, the resident again stated that over the weekend a “black lady” CNA had pushed him down on his bed while assisting with care. On 1/9/26, during an in-person interview with a counselor, the resident reported that the CNA became physical with him during his evening cares on 1/3/26, while also stating he had a sense of safety in the care setting and denied feeling intimidated by others. The facility’s abuse policy required that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported to the state survey agency immediately but not later than 2 hours, based on real clock time. The failure to ensure that this resident’s abuse allegation was reported to the state within the required time frame constituted the cited deficiency.
Failure to Maintain Exit Door Alarm Resulting in Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident identified as at risk for elopement, resulting in the resident leaving the building through an east exit door that was not alarmed or monitored. On the evening in question, an RN was unable to locate the resident at approximately 9:00 p.m. and initiated a search of the building, including rooms, closets, bathrooms, beds, and ancillary rooms. During this process, staff noted that the east door alarm was turned off, even though the resident’s care plan and the facility’s elopement policy required exit door alarms to remain on at all times for residents at risk of elopement. The resident involved had a primary diagnosis of unspecified dementia with behavioral disturbances and a severely impaired cognition score on the Brief Interview for Mental Status. He had been assessed multiple times as having a potential risk for elopement, with elopement risk scores documented on admission and quarterly, and his care plan included interventions such as keeping all doors alarmed to alert staff and redirecting him if he was observed heading toward an exit. Despite these identified risks and care plan interventions, an LPN reported that she had turned off the east door alarm earlier that evening to allow another resident and family to enter without triggering the alarm and then forgot to turn it back on. Staff later confirmed that the door alarm did not sound when the resident exited the building. After the resident was discovered missing, staff and visitors searched the facility and surrounding area. A citizen and his dog ultimately found the resident sitting on the ground in a neighbor’s yard across the street and alerted the search party. Weather data from a nearby personal weather station showed that at the approximate time of the elopement, the outdoor temperature was 7°F with wind speeds of 7 mph, resulting in a wind chill of approximately -5°F. When the resident was brought back inside, he was described as very cold to the touch, with an initial temperature of 96.4°F, and was noted to be combative and resistive to care, grabbing at staff and attempting to hit others, which staff reported was not his normal behavior. Subsequent observations and skin assessments showed no signs of frostbite, and his behavior documentation indicated that his behaviors returned to baseline after the incident.
Failure to Provide Timely Repositioning, Continence Care, and Care Plan–Directed Assistance
Penalty
Summary
Non-compliance with F684 occurred when one resident was not repositioned or provided continence care for approximately nine hours during an overnight shift. Camera footage confirmed that between 8:30 p.m. and 5:41 a.m., the resident did not receive repositioning or incontinence care. The facility’s investigation identified that the staff assignment sheet had not been updated to reflect that two CNAs were splitting the overnight shift, and there was no hand-off communication between the CNAs when one left and the other began the split shift. As a result, the resident’s routine checks and care needs were not carried out during that time period. Additional non-compliance involved another resident whose care plan required "Cares in Pairs," meaning two staff were expected to be present when providing care due to the resident’s history of manipulative behavior, verbal abuse toward staff, recording staff without their knowledge or permission, and making false accusations or statements about staff. Despite this care plan intervention, a CNA assisted the resident with toileting alone, without a second staff member present. The incident was discovered during the investigation of an unrelated event, and there were no adverse consequences reported as a result of this failure. The resident was observed later receiving assistance from two CNAs and reported satisfaction with her care and caregivers. A third incident of non-compliance occurred when a resident who was assigned to a CNA activated her call light for incontinence care and experienced a significant delay before her brief was changed. At the time the call light was activated, the assigned CNA exited another resident’s room, entered the resident’s room, turned off the call light, and then returned to the previous room instead of providing care. Later, the CNA was approached by a family member of another resident and appeared to respond to that request. More than an hour after the initial call light activation, the resident was heard hollering from her room. Another CNA informed the assigned CNA, who dismissed the hollering as the resident wanting her dinner tray removed. A different CNA was then asked to check on the resident and found that the resident had a bowel movement coming out of her brief, with fecal matter on the bedding that appeared to have been present for some time. The resident later confirmed she had soiled her brief and that it took approximately one and a half to two hours before a CNA came to change her. Across these three events, the deficiencies centered on failures to provide timely and appropriate care according to orders, care plans, and residents’ needs and preferences. In the first case, lack of updated assignments and hand-off communication led to missed repositioning and continence care. In the second, a CNA did not follow a clearly documented care plan requiring two staff for care. In the third, the assigned CNA did not respond to a resident’s call light and vocal requests for incontinence care in a timely manner, resulting in prolonged exposure to soiled conditions, even though the resident reported that her care was usually provided promptly and that this was an isolated event.
Failure to Honor Resident DNR Status During CPR
Penalty
Summary
Staff failed to follow a resident's documented Do Not Resuscitate (DNR) code status when the resident was found unresponsive with no pulse or respirations. Despite the presence of an advance directive and an active physician's order indicating DNR/DNI status, staff initiated and continued cardiopulmonary resuscitation (CPR) for approximately 20 minutes before the Director of Nursing (DON) arrived and instructed them to stop after verifying the resident's code status. The nurses involved reported that they began CPR, checked the code status, but continued resuscitation efforts under the belief that once CPR was started, it should not be stopped until emergency medical services arrived. The resident's code status was documented in both the electronic medical record (EMR) and on hall sheets that staff were expected to carry. Interviews revealed that while some staff understood the need to verify code status before initiating CPR, others did not follow this protocol during the incident. Additionally, a certified nursing assistant (CNA) reported that orientation training did not specifically address code status procedures, and the DON was unable to provide signed documentation verifying which staff attended a post-incident educational meeting on advance directives and code statuses. Facility policies required staff to provide basic life support, including CPR, unless a valid DNR order was in place, and indicated that code status information was accessible in the EMR and hall sheets. However, there was no evidence of ongoing auditing or monitoring to ensure staff awareness and adherence to these protocols at the time of the incident. The failure to verify and honor the resident's DNR status before and during resuscitation efforts constituted the deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
Two residents eloped from the facility on separate occasions by exiting through the front door without staff knowledge. In both incidents, the residents were mistaken for visitors by staff members, which allowed them to leave the premises unsupervised. The facility's front door alarm system was bypassed using an employee's badge, enabling the door to be opened without triggering an alert. In the first incident, a resident in a wheelchair independently left the facility when a visitor opened the front door, and was later found sitting outside alone. In the second incident, another resident, also in a wheelchair, exited the facility when two CNAs held the door open after their shift, not recognizing her as a resident or being aware of her elopement risk status. The first resident had a moderate cognitive impairment with a BIMS score of ten and diagnoses including hypertension, venous thrombosis, TIA, and tachycardia. Although his initial elopement risk evaluation determined he was not at risk, he was found outside alone and was unaware of his location or the events when interviewed. The second resident had a severely impaired cognition with a BIMS score of three, a history of wandering, and was identified as high risk for elopement. She was found outside with another resident who was permitted to go out alone, but she herself was not allowed to do so without staff supervision. She did not recall the incident during her interview but was aware that she needed staff accompaniment to go outside. Staff interviews revealed a lack of awareness regarding which residents were at risk for elopement, despite the existence of an elopement binder with photos and information at key locations in the facility. Some staff members, particularly newer employees, were not familiar with all residents or had forgotten about the elopement binder and its purpose. The front door's security system was compromised by staff badges, which allowed residents to exit undetected when accompanied by staff or visitors. These actions and inactions led to the failure to provide adequate supervision and prevent accident hazards, resulting in the deficiency.
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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