Avantara Pierre
Inspection history, citations, penalties and survey trends for this long-term care facility in Pierre, South Dakota.
- Location
- 950 East Park Street, Pierre, South Dakota 57501
- CMS Provider Number
- 435047
- Inspections on file
- 24
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avantara Pierre during CMS and state inspections, most recent first.
A resident with multiple chronic conditions reported acute pain and lack of pain medication to a nurse consultant. The night shift RN did not notify the on-call physician for pain medication orders, citing abnormal labs, and only offered non-pharmacological interventions, which were refused. No documentation of the pain complaint or interventions was made, and the process for contacting the on-call physician was not clearly posted or included in orientation, resulting in a deficiency in pain management.
A resident with frequent loose stools due to lactulose for hepatic encephalopathy was not provided personal hygiene after an incontinent episode before being sent to the ER. The RN on duty, aware of the resident's condition, did not clean the resident prior to ambulance transport, resulting in the resident arriving at the hospital in a soiled state and feeling distressed by the situation.
A resident with hemiparesis, diabetes, and impaired mobility was admitted at high risk for pressure ulcers, but physician-ordered prevention interventions such as an air mattress and heel protection were not implemented or documented. The care plan did not include these measures, and the resident developed a new pressure ulcer before any prevention equipment was provided. Staff confirmed that required interventions were not in place prior to the ulcer's development.
Fifty residents who signed arbitration agreements at admission were not given the required 30-day period to rescind the agreement, as the document only allowed 10 days. A resident interviewed was unaware of the arbitration agreement details, and the administrator confirmed all affected residents received the same version. The facility's policy stated a 30-day rescission period, but the agreement provided to residents did not match this policy.
Three residents experienced cold and uncomfortable room temperatures, as confirmed by observations and temperature readings below the facility's required range. Residents reported having no control over their room temperatures and used extra blankets or walked the halls to stay warm. The facility's boiler system and leaking windows contributed to the issue, and only maintenance staff could adjust locked thermostats, which were not located in resident rooms.
Four residents did not have their care plans accurately updated or interventions implemented as required, including missing or improperly placed fall mats and call lights, lack of documented pressure ulcer prevention measures, failure to provide a required positioning alarm, and omission of physician-ordered lymphedema wraps from the care plan. These deficiencies were identified through observations, interviews, and record reviews.
Staff did not follow enhanced barrier precautions when providing direct care to a resident with a catheter, MDRO, and a pressure injury, as gloves were used but gowns were not worn. In the whirlpool tub room, CNAs failed to use the correct disinfectant and cleaning procedure as outlined by the manufacturer's instructions, and cleaning products were not properly labeled or dated. The laundry room had uncleanable surfaces due to damaged flooring and walls, improper airflow from a fan, and lift slings stored on the floor, with cleaning logs showing incomplete maintenance.
A resident was allowed to self-administer medications, including a nebulizer treatment and nasal spray, in their room without staff supervision or a physician's order, despite an evaluation indicating the resident was not able to self-administer medications. Staff left medications at the bedside, and the DON confirmed the absence of required authorization and assessment per facility policy.
A resident with a history of burns from smoking and mental health conditions was not assessed for smoking risks as required by facility policy. The care plan called for staff supervision and safety measures during smoking, but quarterly and readmission smoking risk assessments were missed. Staff interviews revealed confusion about who was responsible for completing these assessments, and the EMR system did not prompt for them, resulting in a failure to ensure adequate supervision and accident prevention.
Failure to Notify Physician and Document Acute Pain Complaint
Penalty
Summary
A resident with multiple significant diagnoses, including cirrhosis of the liver, diabetes mellitus type II, cardiomyopathy, unspecified convulsions, difficulty with walking, and glaucoma, reported acute stomach pain to a senior regional nurse consultant. The resident also expressed concerns that two night nurses were not providing water or pain medication. At the time, the resident did not have any physician orders for pain medication, and his care plan included interventions for pain management, such as asking for medication and having pain levels reviewed every shift. On the night in question, the registered nurse (RN) on duty was aware of the resident's pain complaint but did not notify the on-call physician to obtain an order for pain medication. The RN cited concerns about the resident's abnormal lab values, specifically elevated liver enzymes and low platelets, as reasons for not administering acetaminophen or ibuprofen. Instead, the RN offered non-pharmacological interventions, such as repositioning, which the resident refused. The RN did not document the resident's pain complaint, the interventions offered, or the resident's refusals in the progress notes. The RN reported the situation to the oncoming nurse but did not take further action to address the resident's pain during her shift. Interviews with facility staff revealed that the process for contacting the on-call physician was not clearly posted or included in the nurse orientation checklist at the time of the incident. The director of nursing expected that nurses would notify the on-call physician if a resident without pain medication orders complained of pain, but this expectation was not met. The lack of timely physician notification and absence of documentation regarding the resident's pain and interventions led to the deficiency in providing safe and appropriate pain management.
Failure to Provide Personal Hygiene Prior to ER Transfer
Penalty
Summary
A resident who was cognitively intact and recently admitted to the facility experienced an episode of incontinence with loose stool prior to being transported to the emergency room (ER) for evaluation. The resident had a history of frequent loose stools related to lactulose use for hepatic encephalopathy and was on a strict fluid restriction. On the evening of the incident, after a total bed change was completed following an earlier incontinent episode, the resident again became incontinent of loose stool just before the arrival of the ambulance team. The registered nurse (RN) on duty was informed by the paramedic about the resident's condition. Despite this, the RN did not provide personal hygiene or clean the resident before transport, citing concern about making the paramedics wait. The resident was subsequently transported to the ER in a soiled state. Upon arrival at the hospital, staff there expressed their dissatisfaction with the resident's condition, and the resident reported feeling bad about the situation. The resident also stated that staff had time to change him before he left for the hospital and recalled hearing the paramedic inform the RN of his incontinence. The facility's policies on abuse, neglect, and resident dignity require that residents be provided necessary care to avoid harm or pain, including personal hygiene after incontinence. The failure to provide personal hygiene to the resident prior to ER transfer, despite awareness of his needs and the opportunity to address them, constituted neglect and a violation of the resident's right to dignity and proper care.
Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to identify and implement pressure ulcer prevention interventions for a resident who was at high risk for skin breakdown and dependent on staff for activities of daily living. Upon admission, the resident was assessed as high risk for developing pressure ulcers, with a Braden score dropping from 18 to 6 within four days, but there was no documentation that physician-ordered interventions such as the use of an air mattress, floating heels, or pressure redistributing cushions were initiated. The resident's care plan did not reflect these interventions, and there was no evidence that the pressure ulcer prevention and treatment orders were implemented upon admission. Observations revealed that the resident was using blue padded pressure-reducing boots and a compression stocking, but these were only provided after a pressure ulcer was identified on the right heel. The resident did not have an air mattress on the bed as ordered, and staff interviews confirmed that the required interventions were not in place prior to the development of the pressure ulcer. The wound care nurse and DON both acknowledged that the resident developed a new pressure ulcer after admission and that the prevention measures were not included in the care plan or implemented as required. The facility's policy required a plan of care for residents at risk for skin breakdown and immediate implementation of individualized prevention programs based on assessment. However, the lack of documentation and failure to follow physician orders and facility policy led to the development of a facility-acquired pressure ulcer in a resident with significant risk factors, including hemiparesis, diabetes, and impaired mobility.
Failure to Provide Required 30-Day Rescission Period for Arbitration Agreements
Penalty
Summary
The provider failed to ensure that 50 out of 55 residents who signed an Arbitration Agreement upon admission were explicitly granted the right to rescind the agreement within 30 calendar days, as required. Observation and interview with a cognitively intact resident revealed she was unaware of the specifics of the Voluntary Agreement for Arbitration she had signed and did not recall signing it. Review of her admission documents confirmed the inclusion of arbitration information, but the agreement itself only allowed a 10-day rescission period, contrary to regulatory requirements. Further review of the provider's undated Voluntary Agreement for Arbitration and policy showed a discrepancy: while the policy stated a 30-day rescission period, the actual agreement given to residents only allowed 10 days. The administrator confirmed that all residents admitted after the 2019 implementation had signed the same agreement and was unsure why the agreement did not reflect the 30-day period. The social services director, responsible for reviewing the agreement with residents, was unavailable for interview during the survey.
Failure to Maintain Adequate Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain adequate room temperatures for three residents who reported their rooms were cold and uncomfortable. Observations confirmed that the rooms of these residents felt colder than other areas of the facility, and residents were observed using extra blankets, wearing additional clothing, and placing items along windows to block drafts. Residents reported having no control over their room temperatures and described ongoing discomfort, with one resident stating she had to stay in bed under blankets to keep warm, and another walking the halls to warm up. Temperature measurements taken in one resident's room showed readings below the facility's required range, with wall temperatures as low as 65.3°F, despite the facility's policy stating that resident room temperatures should be maintained between 71 and 81°F. The maintenance director acknowledged the difficulty in maintaining consistent temperatures due to the building's boiler system and leaking windows, and confirmed that thermostats were not present in resident rooms and were locked to prevent resident or staff adjustment. Only maintenance staff could adjust the thermostats, which were set between 70 and 72°F, and temperature checks were performed by averaging readings from a few rooms. Interviews with staff and review of facility policies confirmed that residents did not have the ability to control their own room temperatures and that complaints about cold rooms had been raised previously, including at a resident council meeting. The facility's homelike environment policy emphasized the importance of comfortable temperatures, but the observed conditions and resident reports demonstrated that the facility did not ensure a safe, comfortable, and homelike environment as required.
Failure to Implement and Update Resident Care Plans and Interventions
Penalty
Summary
The facility failed to ensure that care plans accurately reflected the current needs of four residents and that interventions listed in the care plans were implemented as directed. For one resident with a history of falls and severe cognitive impairment, observations revealed that the fall mat was not properly placed and the call light was not within reach, contrary to the care plan instructions. The resident's care plan specifically required the bed to be in a low position, a fall mat to be placed next to the bed, and the call light to be accessible, but these interventions were not consistently provided. Another resident, who was admitted with hemiparesis and later developed a pressure ulcer on the right heel, did not have appropriate pressure ulcer prevention interventions included in the care plan. Although physician orders and staff interviews indicated the need for an air mattress, pressure-reducing boots, and regular repositioning, these interventions were not documented in the care plan prior to the development of the pressure ulcer. The resident was only provided with pressure-reducing boots after the ulcer was identified, and there was no documentation of air mattress use or trial. A third resident, who required a positioning alarm (tabs alarm) as per physician orders and care plan, was repeatedly observed without the alarm in place while in bed or in a wheelchair. Staff interviews confirmed that the use of the tabs alarm was not consistently communicated or implemented. Additionally, a fourth resident with lymphedema received daily Ace wrap treatments from therapy staff as ordered by a physician, but this intervention was not included in the resident's care plan. Nursing staff were not trained on the use of the wraps, and the care plan did not address this aspect of care, despite expectations from facility leadership that all treatments should be reflected in the care plan.
Infection Control Deficiencies in Resident Care, Whirlpool Cleaning, and Laundry Room Maintenance
Penalty
Summary
Staff failed to follow appropriate infection control practices in several areas of the facility. Two certified nursing assistants (CNAs) did not use gowns while providing direct care, including personal hygiene and changing undergarments, to a resident who had a catheter, a multidrug-resistant organism (MDRO), and a pressure injury. The signage on the resident's door and the care plan both indicated that enhanced barrier precautions (EBP), including the use of gloves and gowns, were required during high-contact care activities. However, the CNAs only wore gloves and did not believe gowns were necessary unless they were emptying the catheter, which was inconsistent with facility policy and the infection preventionist's expectations. In the whirlpool (WP) tub room, two CNAs used different disinfectant products to clean the tub between resident uses, but neither followed the manufacturer's instructions. The spray bottles used for cleaning were not dated, and there was no indication of the required wet contact time for effective sanitization. The manufacturer's manual specified the use of a particular disinfectant, a long-handled brush for cleaning, and a specific procedure, none of which were followed. The director of nursing confirmed that the correct process was not used and that the required disinfectant was not available. The laundry room was also found to have multiple infection control deficiencies. There were uncleanable surfaces due to cracked or missing tiles and peeling paint, both in the main laundry area and the clean linen room. A wall-mounted fan was positioned to blow air from the soiled to the clean area, and mechanical lift slings were stored in a way that allowed them to touch the floor and accumulate dust. Cleaning logs for the laundry room were incomplete or missing for several days, and the infection preventionist confirmed that the areas were not being maintained or cleaned as expected.
Failure to Ensure Safe and Authorized Self-Administration of Medications
Penalty
Summary
A resident was observed self-administering medications, including a nebulizer treatment, Tums, and Fluticasone Propionate nasal spray, in his room without staff supervision. The resident stated he was able to independently manage his medications, and nurses left medications on his bedside table for him to take. Observations confirmed that no staff were present during the administration of the nebulizer treatment, and medications were accessible to the resident in his room. Review of the resident's electronic medical record revealed that a self-administration evaluation had been completed, which indicated the resident was not able to self-administer medications. Additionally, there was no physician order authorizing the resident to self-administer his medications, as required by the facility's policy. The DON confirmed both the lack of a physician order and the evaluation's findings. Staff interviews further indicated uncertainty about the resident's assessment status and the practice of leaving medications in resident rooms.
Failure to Complete Required Smoking Risk Assessments for Resident with Smoking-Related Injury History
Penalty
Summary
The facility failed to implement its smoking policy for a resident with a known history of smoking-related burns and mental health conditions, including paranoid schizophrenia. The resident's care plan required staff supervision during smoking, use of safety equipment such as a cigarette extender and protective apron, and storage of smoking materials in a locked area. Despite these interventions, the facility did not complete required smoking program evaluation assessments at admission, readmission, quarterly, and after hospitalization, as mandated by their policy. Specifically, there were no quarterly assessments between December 2023 and August 2024, and no assessment was completed upon the resident's return from hospitalization. Interviews with staff revealed confusion and inconsistency regarding responsibility for completing smoking risk assessments. Some staff believed floor nurses were responsible, while others stated that only the DON or a specific RN completed them. The EMR system did not automatically prompt for these assessments, contributing to missed evaluations. Staff were aware of the resident's need for supervision and the storage of smoking materials, but the lack of timely and consistent assessments represented a failure to ensure adequate supervision and accident prevention as required by facility policy.
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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