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
A resident with dementia, severe cognitive impairment, a history of wandering and elopement, and a documented elopement risk assessment score exited the building unsupervised through a bedroom window that lacked an effective safety stopper and had no functioning window alarm, despite the care plan indicating one was in place. Staff last saw the resident around midnight and discovered him missing several hours later, finding the window open with the screen pushed out and later locating the resident outside. Surveyors observed multiple unsecured sliding windows in resident rooms and common areas, including the TV lounge, restorative room, therapy room, chapel, and other rooms, many of which could be opened wide enough for a person to climb out, even near residents identified as elopement risks. Several exit doors were unlocked, unalarmed, or not routinely checked, and staff, including the DON and CNAs, were not fully aware of the resident’s exit-seeking behaviors or of required window alarm interventions, leading to a deficiency at F689 for accident hazards and inadequate supervision.
A resident with Parkinson’s disease, a history of falls, and intact cognition routinely used a whirlpool tub chair without the safety belt, despite manufacturer instructions that all users must be securely belted and facility education stating all residents are to use the strap unless refusal is care planned. The resident’s care plan noted she may or may not use the belt, but her record lacked documentation that she was assessed as not requiring it or that she was educated on the risks and potential adverse outcomes of not using it. The resident reported she was not really aware she could fall by not using the belt, while staff indicated all other residents used the safety belt unless otherwise care planned, and leadership acknowledged there was no documentation of the claimed safety education.
A resident with severe cognitive impairment, dysphagia, and an order for a pureed diet with nectar-thick liquids was given an Uncrustable sandwich, a mechanical soft food, by a CNA after consultation with an LPN. Both staff were aware of the resident’s prescribed diet, and the resident had a history of coughing or choking with meals. After taking several bites, the resident began choking, prompting the CNA to initiate back blows and the LPN to perform the Heimlich maneuver and chest thrusts until food remnants were removed from the airway and mouth. The resident was then monitored, and the incident was reported to family, the physician, hospice, and facility leadership. The facility’s pureed diet policy required smooth, lump-free, extremely thick foods and did not permit transitional foods without SLP or physician assessment, which the sandwich did not meet.
A resident with MS, non-ambulatory status, a mild Braden risk score, and an existing unstageable left heel pressure ulcer had a care plan and MD orders requiring frequent repositioning, use of an air mattress and cushions, and heel boots each shift. Over multiple observations, the resident was seen in a wheelchair, recliner, and in bed for extended periods without heel boots or heel offloading, and staff did not reapply the heel boot after wound care. CNAs and a medication aide relied on CNA sheets that lacked specific instructions for heel boots and hourly repositioning in a chair, and one CNA reported only using heel boots in the wheelchair, not in bed or a recliner. The DON confirmed the ulcer originated after ACE wrap use for edema and acknowledged that the ordered repositioning frequency and care plan interventions were not being implemented.
Dietary staff failed to follow dietitian-approved menus and serving sizes for resident meals. A cook routinely served reduced portions of vegetables, side dishes, and protein without consulting the menu, used smaller scoops than required, and varied chicken portions based on resident gender, even when diet cards did not indicate small portions. Menu review showed required serving sizes of three ounces of protein and four ounces of vegetables or pureed items, with no formal small-portion diet, despite several residents requesting smaller portions. The dietary manager reported that staff were expected to use menu books and a binder with serving sizes, but a newly hired dietary aide, trained by the same cook, was also observed serving only two-ounce portions of mashed potatoes and ground beef instead of the ordered amounts.
Surveyors identified multiple food safety and sanitation failures, including staff using the same disposable gloves to handle surfaces and then directly touch RTE food and dishware, and a dietary aide preparing deli sandwiches for staff and residents without changing gloves or performing hand hygiene after leaving and re-entering the kitchen. Thermometer probes were stored in sanitizer containing food debris and were wiped on a cloth instead of being sanitized with alcohol wipes before checking food temperatures. The kitchen and walk-in cooler had heavy dust on vents, fans, ceilings, and light fixtures, and the commercial dishwasher had significant food scum and limescale buildup, with many missed deliming sessions and numerous undocumented dish machine temperatures despite policy requirements. Potentially hazardous foods were left at room temperature for extended periods, raw bacon was stored above RTE mashed potatoes, frozen beef patties were left uncovered in the freezer, and multiple expired or visibly spoiled items, including flavor extracts, food coloring, coffee syrups, relish, and dressing with apparent mold, were found in storage without appropriate dating or rotation.
Surveyors found that the facility failed to implement a formal water management program for Legionella. The maintenance director maintained the in-line water heater at 117–118°F, below the 122–125°F range required for Legionella control, did not add chemicals for Legionella prevention, did not test building water for chlorine, and had no documented plan for flushing stagnant water in empty rooms. A city water employee confirmed chlorine testing was done only at an upstream site, not at the facility. The DON/infection preventionist and the administrator both stated they expected maintenance to follow federal Legionella guidelines, but the administrator acknowledged that staff turnover led to no monitoring, no formal process for flushing stagnant water, and no system to ensure appropriate water temperatures. The Infection Prevention and Control Policy in effect did not address Legionella management or prevention, creating a facility-wide deficiency with potential impact on all residents, staff, and visitors.
Surveyors found that medications and medical supplies were not properly stored, labeled, or secured. In the medication room, multiple expired respiratory test swabs, wound culture supplies, catheter drainage bags, self-cath kits, female straight catheters, and emergency airway/oxygen items in the code box were present, even though the code box had been used on a resident the previous day. On two medication carts, several residents’ insulin pens and inhalers were opened or in use but not dated, and two opened glucose test strip bottles were also undated. Staff, including an LPN/DON in training and the DON, described expectations that insulin pens and inhalers be dated and carts checked regularly, while a pharmacist confirmed insulin should be dated once removed from refrigeration. Surveyors additionally observed two medication carts left unlocked and unattended in hallways, one with a resident sitting in front of it, despite facility policy requiring carts to remain locked or under visual control when not in close proximity.
A nurse documented multiple HS and morning medications as given in the eMAR without actually administering them, and applied an incorrect Fentanyl patch dose to a resident. An internal audit found that numerous medications for several residents remained in bubble packs for the relevant HS and morning passes, even though they were signed out as administered. Affected residents, many with cognitive impairment, did not receive ordered medications such as antiseizure drugs, blood pressure medications, antidepressants, antipsychotics, thyroid replacement, GI agents, and sleep aids. The facility’s own medication administration policy, which requires accurate administration and documentation and proper handling of unadministered doses, was not followed.
A resident received fast-acting insulin from an LPN before breakfast, and despite staff expectations that the resident would be awakened, have the meal tray set up, and eat within 20–30 minutes, observations later that morning showed the resident still asleep with an untouched tray and no documented blood glucose monitoring. In a separate case, another resident routinely wore bilateral compression stockings applied by staff for lower extremity edema, but review of the EMR and TAR showed no active MD order for the stockings despite prior related orders being discontinued, and the DON confirmed an order and treatment entry should have been present; the facility also lacked a policy for transcribing and communicating MD orders.
Failure to Secure Windows and Exits for Elopement-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident at known risk for elopement, who left the building unsupervised through his bedroom window. The resident had dementia with severe cognitive impairment, anxiety, a documented history of wandering and elopement, and an elopement risk assessment score indicating he was at risk for eloping. He had a physician’s order for a WanderGuard and was identified as a wander risk. On the night of the incident, staff last observed him around midnight; at 4:10 a.m. a CNA entered his room and found him missing, with his window open and the screen pushed out. Staff searched the building and then the grounds, ultimately finding him lying in the grass outside at approximately 4:38 a.m., wearing layered clothing, with no major injuries and normal vital signs. The facility’s own investigation determined that the resident’s bedroom window did not have a safety stopper in place at the time of the elopement, allowing it to be opened far enough for him to climb out. Although the care plan indicated that a window alarm had been placed on his window on the date of the incident, later observation by surveyors showed that there was no alarm on his window, only metal stoppers. The executive director stated that an alarm purchased after the incident did not fit the window and that another had not yet been ordered, and the maintenance director had not informed her of this. Staff interviews revealed that direct care staff were not aware that the resident was supposed to have a window alarm, and his Kardex and pocket care plan did not indicate a window alarm requirement, despite his exit-seeking and wandering behaviors, which included standing by exit doors with his coat and belongings and becoming more upset after family visits. Beyond this resident’s room, surveyor observations on multiple dates showed that numerous other windows and doors throughout the facility were not adequately secured, despite the presence of other residents identified as being at risk for elopement. Several sliding windows in common areas such as the TV room, restorative room, therapy room, chapel, and multiple resident rooms could be opened far enough for a person to climb out and lacked metal stoppers. Some rooms near these unsecured windows housed residents at risk for elopement. Certain windows had stoppers on only one side, allowing the other side to open widely. In addition, several exit doors, including doors in the activity room, near the laundry room and employee break room, and two black doors in the dining room to the courtyard, were found unlocked and/or not alarmed or not properly checked, even though the administrator had attested that all exit door alarms were in working order. The maintenance director acknowledged he had not checked all exit doors since starting employment and had only been oriented to some of the exit doors. The DON reported being unaware of the resident’s exit-seeking behaviors, and CNA behavior documentation was not being completed because nurses were documenting, even though nursing notes largely did not reflect exit-seeking behaviors prior to the incident. These combined inactions and environmental hazards led to the determination of noncompliance at F689 with Immediate Jeopardy. The facility’s policies required elopement risk assessments on admission and at set intervals, updating care plans based on risk, use of WanderGuards for moderate or high-risk residents, prompt response to exit alarms, and completion of missing resident drills on all shifts monthly. The resident’s record showed that elopement risk assessments had been completed and that he was identified as a wander risk with a WanderGuard order, but the environmental controls and care plan implementation did not prevent his unsupervised exit through the window. Staff interviews confirmed that residents had ongoing access to unsecured areas such as the television lounge, restorative therapy room, chapel, and therapy room, and that some of these areas contained windows that could be opened wide enough for egress. The combination of unsecured windows and doors, incomplete implementation of care plan interventions (including the missing window alarm), lack of full awareness of exit-seeking behaviors by key clinical staff, and incomplete maintenance checks on exit doors contributed directly to the resident’s elopement and the broader deficiency related to accident hazards and inadequate supervision.
Failure to Educate Resident on Risks of Not Using Whirlpool Chair Safety Belt
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to use of a whirlpool tub chair safety belt. The facility had prior South Dakota Department of Health facility-reported incidents in which two residents fell when staff did not correctly use an assistive or safety device, including a whirlpool chair safety strap. The provider’s own Bath Chair Safety education stated that all residents are to use the bath chair strap unless the care plan reflects a refusal, and the whirlpool tub manufacturer’s manual required that all residents must always be securely safety belted at the waist when using the lift systems, warning that failure to secure the resident properly could result in injury. The resident at issue was admitted with diagnoses including Parkinson’s disease, diabetes, osteoarthritis, degenerative joint disease of the neck, and a history of an L2 compression fracture and falls. Her care plan documented that she was offered the whirlpool tub chair safety belt but may or may not use it, and she had hand tremors. Her BIMS score of 14 indicated intact cognition. There was no documentation in the electronic medical record that she had been assessed as not requiring the safety belt, and no documentation that she had been educated on the risks and potential adverse outcomes of not using the whirlpool safety belt. Staff interviews and observations showed that, in practice, all residents used the whirlpool chair safety belt except this resident. A CNA reported that all residents wore the safety belt unless the care plan indicated it was not required. The resident stated she used the whirlpool tub chair without the safety belt and reported she was not really aware that she could fall by not using it. The DON and administrator stated that the resident chose not to wear the safety belt and that this decision was reflected in her care plan, and the DON reported she had provided education about safe use of the safety belt, but there was no documentation of this education in the resident’s record, despite the manufacturer’s instructions that all residents must always be securely belted when using the whirlpool chair.
Failure to Follow Ordered Pureed Diet Leads to Choking Incident
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered pureed diet with nectar-thick liquids for a resident with dysphagia, resulting in the resident being given an inappropriate snack texture. The resident had severe cognitive impairment with a BIMS score of 0, diagnoses including Alzheimer’s disease, delusional disorder, depression, restlessness and agitation, and was dependent on staff to ensure physician orders were followed. Nutritional assessments and physician orders documented that the resident was to receive a regular pureed (Level 1) diet with nectar-thickened liquids due to dysphagia and a history of coughing or choking during meals or when swallowing medications. Despite this, staff were aware of the resident’s ordered diet texture and fluid consistency through the Kardex, meal tickets, care plans, and diet orders. On the night of the incident, the resident was awake and walking in the main lobby when he stated he was hungry. A CNA had him sit at a table by the nurse’s station and obtained an Uncrustable sandwich from the kitchen refrigerator after asking an LPN what to get for a snack. The CNA reported that the LPN suggested the Uncrustable sandwich, while the LPN stated she was aware of the resident’s pureed diet with nectar-thick liquids and that the CNA had asked if it was okay, but she did not answer. Both the CNA and LPN acknowledged that the resident had been given Uncrustable sandwiches in the past without apparent problems, and the CNA knew the resident’s ordered diet was regular puree with nectar-thickened liquids. The Uncrustable sandwich is a mechanical soft texture food, not appropriate for a pureed diet as later confirmed by the speech language pathologist. After the resident took several bites of the Uncrustable sandwich, he set it down, stood up, and became unresponsive to verbal inquiry about choking. The CNA initiated back blows and called the LPN for assistance. The LPN immediately began the Heimlich maneuver while the resident was standing, then seated, and eventually on the floor where chest thrusts were performed. Food remnants from the sandwich were visualized in the resident’s mouth and removed by the CNA via finger sweep, with additional small remnants removed by the LPN. The resident subsequently produced phlegm, made noises, and was able to take sips of thickened liquid. Vital signs were obtained and he was monitored in a recliner near the nurse’s station. The incident was reported to the family, physician, hospice, and facility leadership, and both the CNA and LPN were suspended pending investigation for not providing the correct diet texture. The facility’s pureed diet policy specified that foods must be pureed to a smooth, lump-free, extremely thick consistency and that transitional foods are not allowed unless assessed and ordered by an SLP or physician, underscoring that the Uncrustable sandwich did not meet the ordered diet requirements.
Failure to Implement Ordered Heel Offloading and Repositioning for Resident With Unstageable Heel Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow pressure ulcer prevention and treatment interventions for a resident with an existing unstageable pressure ulcer on the left heel and identified risk for pressure injury. The resident had multiple sclerosis, was non-ambulatory and confined to bed or chair, and had Braden scores of 16–17 indicating mild risk. Her care plan, initiated 12/9/25, documented fragile skin, an existing unstageable left heel pressure injury, and directed staff to reposition her at least every hour when in a chair and every two hours at night in bed, and to use pressure-reducing devices including an air mattress, wheelchair/recliner cushion, and heel boots to the left foot as needed. Physician orders included daily wound cleansing and moisturizing cream to the left heel and an order from 8/2/22 for heel boots to be placed every morning, afternoon, and night shift. Surveyor observations over multiple days showed the resident repeatedly seated or lying without heel boots or other heel offloading while remaining in the same position for extended periods. On several occasions, she was observed in her wheelchair or recliner for hours without heel boots, and at one point lying in bed on her back with no heel boots or pillows to offload her heels, remaining in the same position for approximately two and a half hours. During a wound care observation, the DON and wound nurse removed the heel boot to perform care and did not reapply it afterward. Staff interviews confirmed that the wound nurse had instructed staff to leave the heel wound open to air and use a heel boot for cushioning, but this was not consistently done. Additional interviews and record review revealed systemic gaps in communicating and implementing the resident’s pressure ulcer interventions. CNAs and a medication aide reported relying on CNA sheets for direction on repositioning and use of pressure-relieving devices. The CNA sheet for this resident did not include her specific pressure ulcer interventions, such as hourly repositioning in a chair or the need for heel boots, and only directed staff to monitor skin, lay her down after meals, use an air mattress, and place a cushion in her chair. One CNA stated she only applied heel boots when the resident was in her wheelchair and did not understand the need for them in bed or a recliner. The DON acknowledged that the resident’s heel ulcer began as a blister associated with ACE wrap use for edema and stated that residents should ideally be repositioned every two hours, also acknowledging that the care plan directive for hourly repositioning in a chair was not being followed and that care plans should reflect current care needs.
Failure to Follow Dietitian-Approved Menus and Serving Sizes for Resident Meals
Penalty
Summary
The deficiency involves dietary staff failing to follow dietitian-approved menus and prescribed serving sizes for residents’ meals. During a lunchtime observation in the kitchen, a cook reported that most residents requested smaller portions and stated she typically served about four ounces of meat and two ounces of vegetables or side dishes, without referencing the dietitian-approved menu to verify correct serving sizes for each prescribed diet. In the dining room, the same cook was observed using a four-ounce scoop for peas and two-ounce scoops for pureed peas, stewed tomatoes, and mashed potatoes, but only serving one two-ounce scoop of these items instead of the menu-required four ounces. She also served smaller chicken legs to female residents and larger bone-in chicken breasts to male residents, and provided one resident with one scoop of peas (about four ounces), one scoop of mashed potatoes (about two ounces), one scoop of gravy (about two ounces), one slice of bread, and one small chicken leg, despite the resident’s laminated diet card not indicating any request for small portions. Review of the dietary extension menus showed that the menu for the observed day required three ounces of protein, a half-cup (four ounces) of mashed potatoes, and a half-cup of stewed tomatoes or peas, including a half-cup of pureed peas for residents on pureed diets, and that there was no designated small portions diet. A diet orders report indicated that seven residents had requested small portions and two residents were on pureed diets. The dietary manager stated that staff were expected to use a menu book and a binder labeled “Cold Orders” that contained menus and serving sizes for each diet, and that all dietary staff should know how to access and use these diet menu spreadsheets. On a separate observation day, a newly hired dietary aide was seen using a two-ounce scoop for mashed potatoes and ground beef and serving only one scoop of each to residents, after being helped with hot-holding table setup by the same cook. Review of the provider’s menu for that day showed that residents should have received a half-cup (about four ounces) of mashed potatoes and three ounces of roast beef or ground beef for mechanical soft diets, which was not followed.
Widespread Food Safety, Sanitation, and Documentation Failures in Dietary Services
Penalty
Summary
The deficiency involves multiple failures in food handling and glove use, thermometer sanitation, kitchen cleanliness, dish machine temperature monitoring, food storage, and disposal of expired or spoiled food. During breakfast and lunch meal service, a cook and dietary aides wore single-use gloves but did not change them between tasks or after touching potentially contaminated surfaces. With the same gloves, they handled serving utensils, laminated diet tickets, serving tables, aprons, cart handles, and then directly touched food-contact surfaces of plates, slices of toast and bread, and the drinking surfaces of cups. One cook also scooped loose brown sugar into containers with a gloved hand instead of using a utensil. Another dietary aide prepared deli sandwiches for staff and residents, touching bread, sandwich meat, cling wrap, and a permanent marker, then left the kitchen and returned to continue food preparation without changing gloves or performing hand hygiene, despite facility policies stating that gloved hands are a food-contact surface that can become contaminated and that gloves must be changed when soiled or when interruptions occur. The facility also failed to properly store and sanitize food thermometers and maintain a clean and sanitary kitchen environment. Two thermometer probes were stored in a cup of sanitizer solution that contained visible food debris and had not yet been changed from the previous day. Later, when checking the temperature of chicken, the cook wiped a thermometer probe on a cloth sitting on top of a container of papers instead of using available alcohol wipes, contrary to the dietary manager’s expectation that probes be cleaned with alcohol wipes before use. Observations in the kitchen and walk-in cooler revealed thick dust on ceiling vents above the walk-in cooler and freezer, dust accumulation on all four cooler fans and their grates, and dust on the cooler ceiling and light fixtures. The commercial dishwasher had a thick layer of food scum and limescale buildup on the inside of the doors and under the seam where it connected to the dirty dish table, and deliming records showed that several scheduled cleanings from July to December were missed, with only one deliming completed in December. Dish machine temperature logs showed numerous missed entries over several months, despite a policy requiring staff to monitor and record wash and rinse temperatures at each meal and for the director of food and nutrition services to spot-check the logs. From August through mid-February, there were repeated omissions in documenting required temperatures, and a dietary aide assigned to dishwashing duties stated he did not check the dish machine temperature and could not recall the last time he had done so. Food storage practices were also deficient. Cooked beef tips in gravy and beef patties intended for lunch were left on the counter at room temperature from before breakfast service until mid-morning, with measured temperatures in the danger zone, and the cook confirmed the food had been sitting out since before breakfast service began. In the walk-in cooler, raw bacon was stored in a box above RTE mashed potatoes, and in the walk-in freezer, a box of frozen beef patties was left uncovered and open to the air. Additionally, several baking ingredients and flavoring agents on a shelf were past their manufacturer best-by or expiry dates, and in the walk-in cooler, a jug of sweet pickle relish had a lid that was not fully secured and had an unidentified white substance on the inside, while a jug of thousand island dressing had apparent mold on the outside of the container, inside the lid, and on the handle, with no open date marked. The dietary manager stated she was unaware of these expired and potentially moldy items, despite a policy requiring rotation, dating, and monitoring of food to ensure timely use or disposal.
Failure to Implement Legionella Water Management Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the absence of a water management program to mitigate the growth and spread of Legionella. The maintenance director reported that he checked the in-line water heater temperature every morning and maintained it at 117–118°F, despite the requirement for water temperatures to be 122–125°F for Legionella control. He also stated that no chemicals were added to the water for Legionella prevention, the building’s water was not tested for chlorine levels, and there was no formal plan or documentation for flushing stagnant water in empty rooms, even though he or housekeeping sometimes ran the water and flushed toilets. Review of water heater temperature logs from November 2025 through February 2026 showed the water heater was consistently maintained at 117°F. A city water employee confirmed that chlorine testing was performed daily at a nearby upstream facility but not at this nursing home. The DON/infection preventionist stated she expected maintenance to follow federal guidelines for Legionella prevention, and the administrator similarly stated she expected maintenance to follow guidelines to prevent Legionella and acknowledged there had been a staff changeover with no one monitoring that the process was being done. The administrator further stated there was no formal process for running stagnant water or ensuring water temperatures were at levels needed to kill Legionella, and that she was responsible for ensuring the water management process was followed. Review of the facility’s Infection Prevention and Control Policy dated October 2025 showed it did not contain information regarding Legionella management and prevention. These findings demonstrated that the facility lacked a formal, implemented water management program for Legionella as part of its infection prevention and control program, with the potential to affect all residents, staff, and visitors.
Improper Medication Storage, Labeling, and Security
Penalty
Summary
The deficiency involves failure to ensure medications and medical supplies were properly stored, secured, and labeled according to professional standards and facility policy. In the medication room, surveyors observed multiple expired medical supplies, including respiratory infection test swabs, a wound culture, urinary catheter drainage bags, self-catheterization kits, female straight catheters, and several emergency airway and oxygen delivery items stored in the code box. Staff reported the code box had been used the previous day on a resident. The LPN/DON in training stated that overnight nurses were responsible for checking outdates during downtime and that a medication aide checked weekly, and acknowledged that expired items should have been removed and that their sterility and function could not be guaranteed if used. On two medication carts, surveyors found multiple insulin pens and inhalers that were opened or in use but not dated, including insulin pens for three residents and inhalers for five residents, as well as two opened glucose test strip bottles that were not dated. The LPN/DON in training stated insulin pens should not be used past expiration and that insulin pens and inhalers were expected to be dated once opened, and that carts were to be checked weekly and by night nurses. Surveyors also observed two separate instances where medication carts were left unlocked and unattended in hallways, one with no staff nearby and another with a resident sitting in front of the cart, while the responsible RN and DON were in or approaching resident rooms. The DON initially stated she did not think insulin pens needed to be dated until used, but the consulting pharmacist stated insulin was to be dated once removed from the refrigerator. The facility’s Administration of Medication policy stated that medication carts should remain locked when the nurse is not in close proximity and that at least visual control must be maintained to prevent unauthorized access.
Multiple Missed and Incorrectly Documented Medication Doses, Including Wrong Fentanyl Patch Dose
Penalty
Summary
The deficiency involves a failure to ensure residents were free from significant medication errors when one LVN documented medications as administered in the electronic MAR (eMAR) without actually giving them, and applied an incorrect dose of a Fentanyl patch to a resident. On two consecutive days, multiple residents did not receive their scheduled HS and morning medications, even though the eMAR showed the medications as given. An internal audit conducted after a resident reported receiving morning medications revealed that, on the Alzheimer Care Unit, most residents’ HS medications from the prior day remained in the bubble cards, and on the main floor, some residents’ morning medications also remained in the bubble cards despite being signed out on the eMAR. The same LVN had also applied a 25 mcg Fentanyl patch instead of the ordered 12 mcg dose to one resident. The medication system in place used bubble cards with 30 individual “bubbles” per card and colored stickers indicating a.m., p.m., or HS passes, and nurses were expected to punch medications out of the bubble cards into a cup, administer them, and then immediately document administration in the eMAR. According to nursing staff, medications that were not administered would remain in the bubble pack for that date, and cards for a completed pass would be moved to the back of the row. However, review and interviews showed that for the HS pass on one date and the morning pass on the following date, medications for multiple residents remained in the bubble packs and the cards were not moved, even though the eMAR entries had been completed as if the medications were given. The DON stated she was not auditing bubble cards for medication errors at the time and had not previously encountered medications being signed out in the eMAR while remaining in the bubble cards before this incident. Record review identified specific residents affected by these errors. One resident with severely impaired cognition and an order for a 12 mcg/hr Fentanyl patch every 72 hours received a 25 mcg patch instead. Another resident with severe cognitive impairment and multiple orders for antiseizure, blood pressure, antipsychotic, and other medications did not receive those HS medications, though they were signed out as given. Additional residents with varying levels of cognitive impairment and intact cognition did not receive ordered medications including antidepressants, antianxiety agents, blood thinners, seizure medications, thyroid replacement, gastrointestinal medications, supplements, and sleep aids, even though the eMAR reflected administration. The facility’s Medication Administration Policy required medications to be administered according to prescriber orders, prohibited using one resident’s medications for another, and required that the individual who administers the medication document directly after giving the dose and document any withheld or unadministered doses per procedure, which did not occur in these events.
Insulin Administration and Compression Stocking Orders Not Managed per Professional Standards
Penalty
Summary
The deficiency involves failure to ensure services met professional standards of quality for two residents. For one resident with diabetes, an LPN administered 5 units of Novolog, a fast-acting insulin, and 42 units of Toujeo, a long-acting insulin, when the resident’s blood glucose was 264 and before the resident had eaten breakfast. The LPN stated that after Novolog administration the resident should eat or drink within 20–30 minutes, and that staff were supposed to wake the resident, set up the room tray, and encourage eating. However, subsequent observations showed the resident remained asleep with an untouched breakfast tray at the bedside more than an hour after insulin administration, and the resident later reported that staff had not awakened her when the tray was delivered and that she had not eaten anything that day. A pharmacist and the DON both confirmed that food intake or blood glucose monitoring should occur within 20–30 minutes after Novolog administration, and the facility lacked an insulin administration policy. The second deficiency concerns failure to ensure a resident had a physician’s order in the EMR and on the TAR for compression stockings that staff were routinely applying. One resident was observed wearing bilateral compression stockings and reported staff put them on each morning to help with lower leg swelling. A CNA confirmed the resident was to wear bilateral compression stockings when out of bed for edema, but on a later observation the resident was not wearing them and stated staff had not applied them that morning. Review of the EMR showed prior and discontinued orders for TED hose, Ace wraps, and compression stockings, including an order to discontinue compression stockings after ankle measurements showed no change, and a later provider progress note referencing the resident going without compression stockings. There was no active physician order for compression stockings at the time staff were applying them, and the DON confirmed there should have been an order in the EMR and a corresponding treatment on the TAR. The facility did not have a policy regarding transcription and communication of physician orders to staff for implementation.
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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