Avantara Huron
Inspection history, citations, penalties and survey trends for this long-term care facility in Huron, South Dakota.
- Location
- 1345 Michigan Avenue Sw, Huron, South Dakota 57350
- CMS Provider Number
- 435020
- Inspections on file
- 24
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Avantara Huron during CMS and state inspections, most recent first.
Two residents experienced preventable safety incidents due to inadequate supervision and failure to follow care plans. A resident with severe cognitive impairment and documented high elopement risk exited through the front door unnoticed after following a staff member, while the receptionist’s view was obstructed by multiple visitors entering, allowing the resident to reach the parking lot before being brought back inside. In a separate event, a resident at high fall risk, whose care plan required one-person assist with a gait belt for transfers, was transferred by a CNA from a bath chair to a wheelchair without a gait belt; the resident could not continue standing and was eased to the floor, resulting in a skin tear to the eyebrow and a large bruise on the upper arm, despite stable vitals and baseline ROM and neuro status.
Two incidents of neglect occurred when CNAs failed to follow care plans. One resident was left in the same clothes and incontinent overnight, while another fell during an improper transfer. Both incidents involved miscommunication and failure to adhere to care plans, resulting in neglect.
The facility failed to maintain sanitary conditions in the kitchen, with improper temperature monitoring and food storage practices. Observations revealed temperature discrepancies in the walk-in freezer and fridge, with no corrective actions documented. Interviews with dietary staff highlighted a lack of knowledge and documentation regarding temperature checks and food disposal. The facility's policies on freezer defrosting, food storage, and temperature recording were not followed, leading to unsanitary conditions.
The facility failed to maintain an ice machine in a sanitary manner, with pink slime and rust observed. Two residents with MRSA were not placed on contact precautions, contrary to policy. An LPN did not follow proper infection control practices during medication administration for a resident on COVID-19 precautions. Staff interviews revealed inadequate cleaning procedures and lack of recent education on infection control.
The facility failed to provide baseline care plan summaries to fourteen residents within 48 hours of admission. Staff interviews revealed that the social services designee did not review or provide summaries due to insufficient training, and the RN did not document the reviews in the EMR. The facility's policy mandates completion of baseline care plans within 48 hours, which was not followed.
A facility failed to provide bed-hold notices to a resident and their representative during two hospital transfers. The resident's records showed three hospital transfers, but only the first included a bed-hold notification. An interview confirmed the lack of documentation for the latter transfers. The facility's policy requires informing residents or their representatives of the bed-hold option at admission and upon each transfer.
A resident's care plan was not updated to include contact precautions after a MRSA diagnosis, and lacked interventions for her behavior of barricading herself in her husband's room. The care plan also did not address the use of family as an intervention, despite their involvement. Additionally, Prevalon boots were used but not listed as an intervention for her wounds.
A resident with a history of surgery and multiple diagnoses reported pain, but the facility failed to provide adequate pain management. Despite having an order for Tramadol, the medication was unavailable due to a missing prescription, and the resident's care plan interventions were not effectively implemented. Interviews revealed a lack of follow-up with the physician and inconsistencies in entering standing orders into the EMR.
A resident requiring dialysis treatment was not properly monitored upon returning from dialysis sessions. The facility failed to consistently document the resident's vital signs post-dialysis, with some entries using outdated data. Interviews revealed that the process for obtaining and documenting these vital signs was not consistently followed, leading to incomplete records.
The facility failed to maintain cleanliness in the kitchen, with range hood vents covered in grease, an ice machine with hard water scale, and stained ceiling tiles. The range hood was not on the weekly cleaning schedule, and maintenance had not cleaned the vents in June. The ice machine was due for replacement, and the ceiling stains were attributed to condensation. The cleaning tasks were marked as completed in previous months, but the provider's policy required compliance with cleaning schedules.
Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Noncompliance With Transfer Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents. In the first incident, a resident with severely impaired cognition, as evidenced by Brief Interview for Mental Status (BIMS) scores of three and zero on prior assessments, had been identified as a high elopement risk with elopement risk assessment scores of five on two separate dates. Her care plan prior to the incident included non-pharmaceutical interventions for wandering, such as cueing, reorienting, supervising, use of an animatronic dog, conversation, walking with her, inviting her to activities, encouraging rest, and providing less stimulation when she was anxious, delusional, or wandering. Despite these identified risks and interventions, the resident was able to exit the building through the front door without staff knowledge. On the date of the elopement, the resident was ambulating with a walker throughout the facility and followed a staff member who was leaving the property out the front door. She exited the building at 2:48 p.m. and was seen outside in the parking lot by the front door at 2:50 p.m., at which time she was escorted back into the facility. The DON later stated that during this elopement, a staff member let in five family members through the front door, which crowded the receptionist’s direct line of sight and prevented the receptionist from seeing the resident use her walker to leave the facility. The DON also stated that residents were mobile and deemed elopement risks, and that if they got outside, it was considered an elopement based on facility policy. The facility’s elopement policy required the facility to take steps to keep residents safe and assess residents to identify those at risk for elopement. The second incident involved a resident with a care plan indicating she was to be transferred with one-person assistance using a walker and a gait belt, and who had been assessed as being at high risk for falls. On the date of the fall, a CNA assisted this resident from a bath chair to her wheelchair without using a gait belt, contrary to the resident’s care plan and the facility’s Transfer and Gait Belt Use policy. During the transfer, the resident was unable to continue standing, and the CNA eased her to the floor, where she was found lying on her right side at the foot of her bed. Assessment by an LPN revealed a one-centimeter skin tear to the right eyebrow, which was closed with a steri-strip, and a light blue bruise measuring ten centimeters by three centimeters on the right upper arm. The resident’s range of motion, neurological assessments, and vital signs were within normal limits, and she reported pain at a level of three on a zero-to-ten scale. The CNA later confirmed he knew a gait belt was required for this resident but did not use one and was unsure why.
Neglect Due to Failure to Follow Care Plans
Penalty
Summary
The provider failed to protect residents from neglect in two separate incidents. In the first incident, a CNA did not provide nighttime care for a resident who was found the next morning in the same clothes from the previous day and incontinent of bowel. The resident had been recently readmitted from the hospital with a history of red and sore buttocks. Despite the resident's care plan being updated upon her return, the CNA and the charge nurse on duty did not ensure the care plan was followed, resulting in neglect. In the second incident, a CNA did not follow the care plan for a resident with moderate cognitive impairment during a transfer. The resident was supposed to be transferred using a stand-up lift during the evening shift, but the CNA attempted a stand and pivot transfer, leading to the resident's fall. The CNA misread the care plan, which clearly indicated the need for a stand-up lift during the evening and night shifts. Both incidents highlight a failure to adhere to established care plans, resulting in neglect. The residents involved had specific care needs that were not met, leading to situations that could have been avoided if the care plans were properly followed. The facility's policies on neglect emphasize the importance of providing necessary and adequate care to avoid harm, which was not achieved in these cases.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The provider failed to maintain clean and sanitary conditions in the kitchen where residents' food was stored and prepared. Observations revealed that the walk-in freezer had temperatures recorded outside the adequate range, with no documented actions taken to address these discrepancies. There was ice build-up around the door, the metal lining was separated, and frost was present on the cooling unit. The three-door fridge unit also had temperature variances without documented corrective actions. Additionally, there were issues with food storage, such as undated chicken nuggets, freezer-burned chicken, and improperly stored meat. Interviews with the dietary manager and aides highlighted a lack of knowledge and documentation regarding temperature checks and food disposal. The dietary manager admitted to not documenting actions taken when thermometers did not match and was unaware of the proper disposal process for food based on package dates. The administrator was aware of the ice build-up but not of the failure to discard partially thawed food. The facility's policies on freezer defrosting, food storage, and temperature recording were not adhered to, contributing to the unsanitary conditions. The provider's policies outlined specific guidelines for freezer defrosting, food storage, and temperature monitoring, which were not followed. Freezers were supposed to be frost-free, and food should not show signs of defrosting or refreezing. The facility's failure to adhere to these policies resulted in unsanitary conditions in the kitchen, with improperly stored and potentially unsafe food items. The lack of documentation and adherence to procedures by the dietary staff further exacerbated the issue.
Infection Control Deficiencies in Ice Machine Maintenance and Resident Precautions
Penalty
Summary
The provider failed to maintain an ice machine in a clean and sanitary manner, as observed in the therapy room. The ice machine had pink slime on the water/ice spout, rusted metal bars over the water tray, and a white, flaky residue on the underside of the machine. Interviews with staff revealed that housekeepers only cleaned the outside of the machine, while maintenance staff were responsible for internal cleaning. However, the maintenance director admitted to using inappropriate cleaning chemicals and not following the manufacturer's instructions for cleaning and sanitizing the machine. The provider also failed to place two residents on contact precautions despite their diagnoses with multi-drug resistant organism (MDRO) infections. One resident had Methicillin-resistant Staphylococcus aureus (MRSA) in her left ankle and was receiving intravenous antibiotics, yet was only on enhanced barrier precautions. Another resident, diagnosed with MRSA in her right ankle wound, was also not advanced to contact precautions. Interviews with nursing staff confirmed the oversight in precautionary measures, which contradicted the facility's MRSA policy. Additionally, infection control practices were not maintained during medication administration for a resident on COVID-19 precautions. An LPN failed to wipe off a nasal spray applicator after use and did not follow proper procedures for handling the nasal spray outside the precaution room. Interviews with staff revealed a lack of recent education on infection control practices, particularly regarding nasal spray administration in precaution rooms. The facility's policies did not address these specific infection control practices.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The provider failed to ensure that fourteen out of twenty-nine residents received a summary of their baseline care plan within 48 hours of admission. The records for residents 10, 23, 46, 49, 53, 55, 64, 65, 67, 70, 224, 274, 375, and 424 showed no documentation that a baseline care plan summary had been reviewed with the residents or their representatives. Additionally, the baseline care plan for resident 424 was not signed as completed until a later date, indicating a delay in the process. Interviews with staff revealed gaps in the implementation of baseline care plans. The social services designee admitted to not reviewing or providing a summary of the baseline care plan to residents or their representatives, citing insufficient training since assuming the position. The clinical care coordinator RN also acknowledged not documenting the review of the baseline care plan in the residents' electronic medical records (EMR). The facility's policy requires that a baseline care plan be started on the first day of admission and completed within 48 hours, which was not adhered to in these cases.
Failure to Provide Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The provider failed to provide bed-hold notices to a resident and their representative during two out of three hospital transfers. The resident's electronic medical record indicated transfers to the hospital on three occasions. While the representative was notified of the bed-hold policy during the first transfer, there was no documentation of such notification for the subsequent transfers. An interview with the social service designee confirmed the absence of documentation for the latter two transfers. The facility's Bed Reserve Policy and Bed-Hold and Return Agreement require that residents or their representatives be informed of the bed-hold policy at admission and upon each transfer, allowing them to request a bed-hold by paying a daily rate.
Failure to Update Resident Care Plan for MRSA and Behavioral Interventions
Penalty
Summary
The provider failed to ensure the timely review and revision of a resident's care plan, specifically for a resident who was admitted with multiple wounds and later diagnosed with MRSA. The resident's care plan initially included Enhanced Barrier Precautions (EBP) due to her wounds, but after the MRSA diagnosis, the care plan was not updated to include contact precautions. Additionally, the care plan did not list Prevalon boots as an intervention for her wounds, despite their use being observed. The care plan also lacked focus areas, goals, or interventions addressing possible complications related to the resident's diagnosis of rhabdomyolysis. Furthermore, the resident had a history of barricading herself in her husband's room, which was noted in her nurse progress notes. However, the care plan did not include interventions for this behavior, nor did it address the use of family as an intervention, despite family being called multiple times to help calm her behaviors. The facility's policy requires individualized, resident-centered care planning to be maintained throughout the resident's stay, with updates reflecting current care needs as changes occur, which was not adhered to in this case.
Inadequate Pain Management for Resident
Penalty
Summary
The provider failed to ensure adequate pain management for a resident who expressed experiencing pain. The resident, who had a history of right-hand surgery, back pain from a fall, and multiple diagnoses including peripheral vascular disease and type 2 diabetes, reported pain on the left side of her body. Despite having an active physician order for Tramadol, a pain medication, the medication was not available on the medication cart, and the resident was informed by an LPN that no pain medication was available. The resident's care plan included interventions for pain management, such as providing analgesics as ordered and notifying the physician if pain relief was inadequate, but these were not effectively implemented. The deficiency was further highlighted by the lack of a written prescription for Tramadol being sent to the pharmacy, which delayed the medication's availability. Interviews with the DON and CCC confirmed that the pharmacy had not received the necessary prescription, and the CCC acknowledged that the provider should have followed up with the physician. Additionally, standing orders for pain control were not consistently entered into the resident's EMR upon admission. The facility's pain management policy outlined procedures for identifying and managing pain, but these were not adequately followed, resulting in the resident's pain not being addressed in a timely manner.
Failure to Monitor and Document Post-Dialysis Vital Signs
Penalty
Summary
The provider failed to ensure proper monitoring of a resident who required dialysis treatment, specifically in documenting vital signs post-dialysis. The resident, who had a dialysis port in his chest and received dialysis three times a week, had a care plan that required significant changes in pulse, respirations, and blood pressure to be reported immediately. However, the resident's electronic medical record showed discrepancies in the documentation of post-dialysis vital signs, with some entries using outdated data from previous dates instead of current readings. Interviews with the registered nurse and the director of nursing revealed that the process for documenting post-dialysis vital signs was not consistently followed. The nurse acknowledged that the vital signs should ideally be taken and documented each time the resident returned from dialysis, but this did not always occur. The director of nursing confirmed that the expectation was for vital signs to be obtained and documented each time, but this was not consistently done, leading to incomplete and inaccurate records for the resident's post-dialysis condition.
Kitchen Cleanliness Deficiency
Penalty
Summary
The provider failed to maintain cleanliness in the kitchen, specifically regarding the range hood vents, ice machine, and ceiling tiles. During an observation, the range hood vents were found to be covered with a greasy film and lint, while the ice machine had a layer of hard water scale build-up on its sides and embedded deposits between the cooling fan fins. Additionally, ceiling tiles above the refrigerator had dark water stains. Interviews revealed that the range hood was cleaned by a contracted service, but the dietary aide was unsure of the last cleaning date, and the range hood was not included in the weekly cleaning schedule. The dietary manager confirmed the lack of a cleaning schedule for the range hood and noted that maintenance was responsible for cleaning the vents, which had not been done recently. The maintenance director used a computer program to track maintenance tasks and stated that the range hood and vents were to be cleaned monthly, but the vents had not been cleaned in June. The ice machine, which had been moved from another area, was cleaned when the kitchen floor was replaced in May, but it was due for replacement. The maintenance director also acknowledged the need to replace the stained ceiling tiles, attributing the stains to condensation from the air conditioning duct. A review of the kitchen exhaust fan log showed that cleaning tasks were marked as completed from January to May 2024, and the provider's cleaning policy required the Food and Nutrition Services staff to maintain sanitation through compliance with written cleaning schedules.
Latest citations in South Dakota
Failure to Follow EBP and Hand Hygiene Practices: Staff did not wear gowns or gloves, did not perform hand hygiene, and did not clean an EZ stand lift after providing high-contact care to a resident on EBP with a Foley catheter. Staff also provided toileting care to a resident with open stage II pressure ulcers without gowns, and a housekeeper handled resident-room surfaces and items with unclean hands while cleaning rooms. Facility policy required gown and glove use for EBP, cleaning reusable equipment between residents, and hand hygiene after resident contact and glove removal.
A resident with severe cognitive impairment, TBI, and dementia with behavioral disturbances used a one-piece jumpsuit identified as a restraint intervention to address genital exposure and related behaviors. The EMR showed consent and physician approval, but the quarterly MDS and care documentation did not show whether the garment remained needed, whether less restrictive alternatives had been tried, or whether restraint reduction or elimination had been considered. Staff interviews confirmed the resident had not worn the garment in a long time, and the DON stated there was no restraint-specific documentation form to track its use or reassess the need for it.
Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
Failure to assess, document, and report new pressure ulcers: A resident with a pelvic fracture and intact cognition developed stage II pressure ulcers on both inner buttocks and a new pressure ulcer on the heel. Staff interviews and record review showed the DON/wound nurse did not document the heel wound or notify the MD, did not notify the MD when the left buttock ulcer was identified, and wound monitoring was not completed daily as required by the facility's own process.
Staff failed to follow a resident’s care-planned transfer needs. The resident had severely impaired cognition, a moderate fall risk score, and required dependent assistance with transfers, including a Hoyer lift with 2 staff or a sit-to-stand lift. Two CNAs lifted her by the underarms and pivoted her instead of using the ordered transfer method, and one CNA stated she did not use a gait belt because the resident was too tiny. The DON acknowledged the transfers were improper and unsafe because staff did not follow the care plan or Kardex.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Staff failed to honor several residents’ stated preferences regarding where they undressed for bathing, affecting their dignity and privacy. One resident reported that a CNA repeatedly undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his expressed wish to undress in the shower room. Other residents described similar experiences, stating that the CNA did not ask their preferences and routinely undressed them in their rooms before covering them with a sheet or blanket and taking them to the tub or shower room. Staff interviews confirmed that residents, particularly those requiring a mechanical lift, were typically undressed in their rooms and then transported covered, and the DON stated that facility protocol was to follow resident preference, consistent with the written dignity and privacy policy.
A resident reported that a contracted travel CNA placed hands down his pants while he was in bed, which he described as groping and not part of his usual care routine. Two RNs received this allegation; one counseled the CNA but did not notify leadership and did not know the required reporting time frame, while the other, who knew the 2‑hour reporting requirement, also failed to promptly inform the DON or administrator, delaying notification to state authorities and omitting contact with law enforcement and the ombudsman. In a separate incident, a resident’s family member reported suspected financial abuse to the social services designee, who informed the administrator, but the concern was not reported to the state agency or investigated as an abuse allegation; instead, the family was only given contact information for outside agencies. These actions did not follow the facility’s abuse policy requiring immediate internal reporting, prompt investigation, and timely reporting of all abuse and misappropriation allegations to the state agency.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
Failure to Follow EBP, Equipment Cleaning, and Hand Hygiene Practices
Penalty
Summary
Infection prevention and control practices were not followed during care for a resident on enhanced barrier precautions (EBP) who had a Foley catheter. During a transfer from a wheelchair to a recliner using an EZ stand lift, two CNAs/RMAs did not wear gowns or gloves, did not perform hand hygiene after the transfer, and one CNA/RMA placed the lift outside the resident’s room without cleaning it. One of the CNAs/RMAs stated she was expected to wear a gown and gloves for the transfer and remove them afterward, and the other stated she should have worn a gown and gloves and cleaned the lift after use. A second resident had open stage II pressure ulcers to both buttocks and a new pressure ulcer on the right heel, but was not placed on EBP. During observed toileting assistance, an RN and a CNA wore gloves but did not wear gowns while providing care to the resident’s open buttock wounds. The CNA applied barrier cream to the pressure ulcers and the rest of the buttocks. The RN stated the resident did not need EBP because the wounds did not have drainage, and the ADON/IP stated the resident was not on EBP because the pressure ulcer was not chronic. Housekeeping staff also did not follow hand hygiene practices while cleaning resident rooms. A housekeeper removed a mop head with bare hands, touched door handles without washing hands, and used unclean hands while moving between rooms and handling resident items and bathroom surfaces. The housekeeper stated she was supposed to wash her hands after cleaning a bathroom, after mopping, and between rooms, and the director of food and nutrition/housekeeping and housekeeping supervisor confirmed staff were to wash hands before and after glove use, after bathroom cleaning, and before and after mopping. Facility policy stated EBP required gown and glove use for high-contact care such as transferring and toileting, reusable equipment was to be cleaned and disinfected between residents, and hand hygiene was the primary means to prevent the spread of healthcare-associated infections.
Lack of Documentation for Ongoing Use of One-Piece Garment Restraint
Penalty
Summary
The provider failed to document whether one resident who used a one-piece jumpsuit as a restraint intervention was a candidate for restraint reduction, a less restrictive restraint method, or restraint elimination. The resident had severe cognitive impairment, a history of traumatic brain injury, and dementia with behavioral disturbances. He was observed seated in his wheelchair at breakfast and later in his recliner, repeatedly moving his feet, rocking his trunk, and placing his hand in and out of the waistband of his sweatpants. His EMR showed that the jumpsuit had been identified as a restraint intervention and that the resident's spouse had signed informed consent for its use. The record showed the resident had ongoing behaviors involving fondling himself and exposing his genitals, and staff requested physician approval for a one-piece garment to protect his dignity and prevent exposure to others. The physician approved the request. The quarterly MDS indicated the resident used a trunk restraint on a less-than-daily basis, and the MDS nurse's note stated that when available the resident would wear the one-piece jumpsuit. However, that assessment did not include documentation supporting continued use or discontinued use of the garment, and there was no indication that other alternatives had been tried. The behavioral tracking record documented other targeted behaviors, but fondling and exposing his genitals were not identified as targeted behaviors on that assessment. During interviews, an LPN stated the jumpsuit's zipper was on the backside of the garment, restricting the resident's access to his genitals, and said he had not worn it in a long time because of physical and cognitive decline. A CNA also stated she had not seen him wear the garment. The MDS nurse found the jumpsuit hanging in the resident's closet and acknowledged she did not know whether staff had completed restraint-related documentation. The DON stated there was no restraint-specific form to document when the jumpsuit was worn, what precipitated its use, what less restrictive interventions were tried, or how long it was worn, and acknowledged that without such documentation the quarterly assessment could not fully determine whether the jumpsuit remained needed or could be discontinued. The facility's restraint policy required least restrictive use, ongoing reevaluation, and quarterly review for restraint reduction, less restrictive methods, or elimination.
Failure to Follow Ordered Urology Consultation
Penalty
Summary
The nursing facility failed to follow a physician-ordered urology consultation for a resident with urinary retention and a Foley catheter. The resident had been hospitalized for a left femur fracture, and hospital records showed the Foley catheter was removed and later reinserted after a failed trial without catheter. After discharge to the skilled nursing facility, the physician was faxed about discontinuing the Foley catheter and responded to start Alfuzosin for 4 days and then attempt a trial without the catheter. When that trial failed, the physician ordered the Foley restarted and follow-up with urology. Subsequent physician progress notes in February, March, and April documented referral to urology for further evaluation and care, and the resident’s catheter care plan addressed Foley care but did not include a plan for removing the catheter. During interviews, an LPN stated she knew the resident was expected to be seen by a urologist but it had not yet occurred and she was not sure why. The DON and ADON/IP stated the physician was expected to call the urologist to make the referral and that the urology office would then confirm the appointment time. The ADON/IP recalled discussing the urology consultation with the physician during January rounds, but confirmed she did not discuss the status of the consultation during February, March, or April rounds and had no other discussions with the physician about it. The DON acknowledged the failure to follow the January physician-ordered urology consultation was 100% on the facility.
Failure to assess, document, and report new pressure ulcers
Penalty
Summary
The provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers for one resident who had returned to the facility from the hospital with a pelvic fracture and weakness and had an intact BIMS score of 15. The resident had a stage II pressure ulcer to the right inner buttock identified on 4/6/26, and later a stage II pressure ulcer to the left inner buttock was identified on 4/27/26. The record showed wound assessments on the right inner buttock, but the report states the wound assessment documentation was not completed weekly as required, and the physician was not notified when the left inner buttock ulcer was identified. The resident was observed sitting in a wheelchair on a Roho pressure-relief cushion and stated she had an open sore on her bottom. Staff interviews confirmed she had pressure ulcers on both inner buttocks, and a CNA reported finding a new pressure ulcer on the resident's right heel that was boggy and dark red and purple in color. An LPN stated the resident had stage II pressure ulcers to both inner buttocks and that the new right heel pressure ulcer had been found the previous day. The DON/wound nurse later stated she was not aware of the right heel pressure ulcer and could not find documentation of it or documentation that the physician had been notified. The record review showed the resident's wound assessments were completed on several dates for the right inner buttock ulcer, with measurements and descriptions documented, and the care plan addressed pressure ulcers to both inner buttocks. However, the DON/wound nurse stated nurses did not monitor pressure ulcers daily and that weekly skin assessments were the routine process. The provider's policy required nurses to document and report pressure ulcers, and the change-in-condition policy required physician notification within 24 hours for a significant change of condition. The DON/wound nurse stated she did not notify the physician when the left inner buttock ulcer was identified and planned to wait until the physician rounded at the facility later.
Unsafe Transfers Not Followed for a Resident With Care-Planned Lift Needs
Penalty
Summary
The nursing home failed to ensure safe transfers for resident 11, who had severely impaired cognition, a moderate fall risk score, and care-planned transfer needs requiring dependent staff assistance. Her revised care plan stated that she usually required a Hoyer lift with staff assist x 2 for transfers when she was not placing her feet on the ground for a pivot transfer with a gait belt and staff assist x 1-2, or a sit-to-stand lift. The resident was observed in the dining room being lifted by CNA F and CNA/RMA E, who each placed an arm beneath her underarms, raised her to standing, pivoted her, and lowered her into her wheelchair. CNA F later transferred the resident from the wheelchair to a recliner in the same manner and stated the resident could not bear her full weight and that she did not use a gait belt because the resident was too tiny. A separate observation showed CNA/RMA G using a sit-to-stand lift to transfer resident 11 from her wheelchair to the toilet and referring to the Kardex to confirm that a mechanical lift was required. The DON/wound nurse stated therapy assessed residents' mobility and transfer needs, those recommendations were added to the care plan, and the care plan information was then transferred to the Kardex so staff would know how to care for the resident. The DON acknowledged that CNA/RMA E and CNA F improperly and unsafely transferred resident 11 by failing to follow the transfer recommendations in the care plan and Kardex.
Failure to Maintain Safe Bed Systems and Prevent Accidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bed environment free from entrapment hazards and to provide adequate supervision and accident prevention for multiple residents. Surveyors observed that several residents had loose side rails or grab bars and mattresses that were not secured or properly fitted, creating gaps between the rails, mattress, and bedframe. One resident’s bilateral side rails could move away from the bed one to two inches, and there was a five‑inch gap between the top of his mattress and the headboard. Another resident, who was legally blind and had previously fallen out of bed during a dream and sustained a brain bleed, had a left side rail that could move three inches away from the mattress; he reported telling a CNA and his daughter about the loose rail about a week earlier. A third resident used bilateral side rails for bed mobility; her right rail could move two to three inches away from the bed, the openings within the rails measured three and one‑half inches wide by 13 inches high, and there was a seven‑inch gap between the foot of her mattress and the footboard. Surveyors also found that the facility’s entrapment assessments and maintenance audits were incomplete or inaccurately documented. Review of the maintenance logbook for side rail inspections from January through April showed that only zone 1 (the opening within the side rail) was consistently assessed, while the other six FDA‑defined entrapment zones were often marked as not applicable, including zone 7 (the space between the mattress and headboard or footboard) even for residents without bed rails. In some months, all seven zones were documented as not applicable for numerous residents known to have side rails, and some residents with side rails were not included in the audits at all. The DON was unsure if there was a specific entrapment assessment policy and believed maintenance handled these assessments, while also acknowledging missing documentation for side rail assessments, consents, and physician orders, and that some side rails were installed without proper documentation. Additional deficiencies related to accident prevention and supervision were identified in several facility‑reported incidents. One resident with a history of stroke and left‑sided weakness fell from his bed while trying to remove his socks after a CNA left his bed at waist height; his care plan at that time did not specify a required bed height, and he was later diagnosed with a minor closed head injury and abrasions. Another resident, care planned to require two staff for transfers and use of a sit‑to‑stand lift, was transferred by a single contracted CNA using a sling that was too small and the wrong hook, causing back pain; the resident and his family reported that he was often transferred by only one staff member despite the care plan. A cognitively impaired resident at risk for elopement exited through a door whose alarm had been deactivated during daytime hours so visitors could enter and exit, walked outside in very cold weather, and re‑entered through another door after about 15 minutes. A further resident, on anticoagulant therapy, fell while transferring herself to the bathroom and hit her head; she had fallen 11 times in 30 days, and the provider failed to implement, review, and revise interventions to reduce her fall risk. These events collectively demonstrate failures to follow care plans, maintain environmental safety devices such as alarms and bed systems, and provide adequate supervision to prevent accidents. The surveyors determined that these failures, particularly the unsecured side rails and unassessed mattress gaps, created a risk for entrapment injury or harm and issued an Immediate Jeopardy finding under F689 related to accident hazards and supervision. Observations throughout the building confirmed multiple safety concerns with side rail installation, maintenance, and bed zone assessments, including loose rails and significant gaps between mattresses and headboards or footboards. Facility leadership and maintenance staff acknowledged that gaps between mattresses and bed ends and loose side rails posed a risk for entrapment and injury, and that entrapment zone measurements and assessments had not been consistently completed according to FDA guidance and facility policy.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Honor Resident Bathing and Undressing Preferences
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity, respect, and self-determination regarding bathing and undressing practices. One resident reported in a facility reported incident that on his bath days, a CNA undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his stated preference to undress in the shower room. During a later interview, this resident stated that the CNA continued this practice, that it made him uncomfortable, and that it happened all the time. The DON stated that the bathing protocol was to follow each resident’s preference for where to undress, and that the CNA had been informed of this resident’s preference. The resident’s care plan documented his need for assistance with dressing but did not include his specific bathing or undressing location preferences. Additional interviews showed that this practice extended to other residents and was not individualized based on resident choice. The CNA acknowledged awareness of the resident’s preference but stated that all residents were undressed in the shower room, while another CNA described a typical routine in which residents with limited mobility who required a mechanical lift were undressed in their rooms, covered with a blanket, and then transported to the shower room. Another resident reported seeing the first resident transported to the shower room covered only by a blanket and stated that the CNA did not ask where he preferred to undress, instead beginning to undress him after announcing it was time for a bath. A third resident stated that the same CNA transferred him from bed to a chair, covered him with a white sheet, and took him to the tub room without asking his preferences, and that he had seen other residents transported in the same manner. These practices conflicted with the facility’s Resident Dignity & Privacy Policy, which required staff to groom and dress residents according to their preferences and to maintain privacy during care.
Failure to Timely Report and Investigate Allegations of Sexual and Financial Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and initiate required investigations into two separate allegations of abuse, including sexual and possible financial abuse. One resident reported that at approximately 6:00 a.m. a contracted travel CNA placed hands down his pants while he was in bed, allegedly to check if he was wet, which the resident described as groping that made him feel cheap. The resident stated he typically did not receive nighttime incontinence checks, as he used a urinal and was usually only awakened for early morning blood sugar checks or lab draws. He reported this incident to two RNs, one of whom acknowledged that it was not appropriate for staff to put their hands down a resident’s pants to check incontinence products. Despite this, the nurses who received the allegation did not immediately report it to the DON, administrator, or state agency as required by facility policy and federal guidelines. One RN spoke with the contracted travel CNA to “educate” her but did not notify anyone else and did not know the required reporting time frame. Another RN, who was aware of the process and the two-hour reporting requirement to the state health department, also failed to promptly report the allegation to the DON or administrator, resulting in a delay until late morning before leadership became aware. At the time leadership was notified, the allegation had not yet been investigated, and law enforcement and the ombudsman had not been contacted, even though the allegation involved possible sexual abuse. A second deficiency arose when a resident’s family member reported concerns of suspected financial abuse to the social services designee, who then informed the administrator. Instead of treating this as an abuse allegation requiring reporting and investigation under the facility’s abuse and neglect policy, the administrator did not report it to the state health department, citing a lack of detailed information. The social services designee and administrator only provided the family with contact information for external agencies such as the state’s attorney and adult protective services. The facility’s own policy required that all allegations and suspicions of abuse, including misappropriation of property and exploitation, be immediately reported to the administrator or designee, investigated by the administrator or designee, and reported to the state agency within two hours, but these procedures were not followed for either the sexual abuse allegation or the suspected financial abuse concern.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
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