Avera Brady Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Mitchell, South Dakota.
- Location
- 500 S Ohlman, Mitchell, South Dakota 57301
- CMS Provider Number
- 435061
- Inspections on file
- 22
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Avera Brady Health And Rehab during CMS and state inspections, most recent first.
Failure to Maintain Hand Hygiene During Meal Prep: During lunch service, a cook dropped a butter container lid on the floor, picked it up, and continued plating food without hand hygiene. She also coughed into her hand while holding a resident plate, drank from her personal cup placed on a food transport cart, and kept preparing resident meals without washing or sanitizing her hands. The ADM and DM gave conflicting views on the beverage placement, but the DM stated the cart top was not a designated space for staff drinks.
A resident with intact cognition, obesity, depression, anxiety, chronic pain, constipation, fibromyalgia, overactive bladder, and bowel/bladder incontinence was left on a commode after her call cord did not activate and staff did not return to check on her. The resident had to yell for help, was found upset after waiting longer than she wanted, and the facility’s orange magnet process for indicating a resident was on the toilet/commode was not followed. The incident was identified as neglect, and the facility also did not assess other residents’ call cords for proper function.
A resident with Parkinson’s disease, a history of falls, and intact cognition routinely used a whirlpool tub chair without the safety belt, despite manufacturer instructions that all users must be securely belted and facility education stating all residents are to use the strap unless refusal is care planned. The resident’s care plan noted she may or may not use the belt, but her record lacked documentation that she was assessed as not requiring it or that she was educated on the risks and potential adverse outcomes of not using it. The resident reported she was not really aware she could fall by not using the belt, while staff indicated all other residents used the safety belt unless otherwise care planned, and leadership acknowledged there was no documentation of the claimed safety education.
The facility failed to provide a written summary of the baseline care plan to several residents within 48 hours of admission, as required by policy. This deficiency was identified through record reviews and interviews, revealing that some residents, including those with severe cognitive impairments and significant medical conditions, did not receive their care plans until days or weeks after admission. The facility's misunderstanding of the regulation and delayed communication contributed to this issue.
Two residents experienced significant delays in call light response, with wait times often exceeding 30 minutes, leading to incontinence and unmet assistance needs. Both residents were cognitively intact and had their call lights within reach. The facility's policy aimed for a 10-minute response time, but this goal was not consistently met, as confirmed by the DON.
A resident was allowed to self-administer a nebulizer treatment without a self-administration medication order. An RN set up the treatment and left the room, failing to monitor the resident. The resident's EMR lacked the necessary self-administration order and evaluation. The DON confirmed that such orders are required for self-administration, and the facility's policy mandates an interdisciplinary team assessment and physician's order, which were not completed.
Failure to Maintain Hand Hygiene During Meal Preparation
Penalty
Summary
Food safety practices were not followed during lunch meal service when cook I dropped the lid to a butter container onto the floor, picked it up, and placed it on the counter next to an open bag of bagels without performing hand hygiene. She then prepared a plate of food for a resident and, while holding the plate in her left hand, coughed into her right hand. After coughing, she continued preparing additional plates of food for residents without washing or sanitizing her hands. Hand sanitizer was available on the counter next to the steam table line and on the north wall of the dining room. During the same meal service, cook I had her personal beverage cup sitting on top of the food transport cart located in the kitchenette next to the serving line. She took a drink from the cup, placed it back on the cart, and continued preparing resident plates without performing hand hygiene. The assistant dietary manager stated the cup location was appropriate, while the dietary manager stated the top of the food transport cart was not a designated space for staff beverages and expected staff to follow the handwashing policy. Cook I acknowledged she should have set the plate down and washed her hands after coughing into her right hand and should have started over with a clean plate.
Failure to Ensure Toileting Checks and Working Call System Cord
Penalty
Summary
The facility failed to provide appropriate toileting assistance and functioning call system access for a resident who required two staff members and a sit-to-stand lift for toileting. Resident 41 had morbid obesity, depression, anxiety, chronic pain, constipation, fibromyalgia, overactive bladder, bowel and bladder incontinence, and a BIMS score of 13 indicating intact cognition. Her care plan stated she used a bedside commode, wanted to be toileted at 4 a.m., used her call light the rest of the time, and needed frequent checks when her door was closed. On 3/5/26, Resident 41 was found sitting on the commode after yelling for help. She stated she had been waiting for someone to answer her call light and had tried to call for help at 4:45 p.m. The RN tested the call light and found it would not activate until the cord was unplugged and replugged. Maintenance later replaced the call system cord and adjusted the placement of the call system box and cord. The facility’s investigation determined that Resident 41 had been on the commode about 30 minutes longer than she wanted to be. The report also states CNA N did not return to the resident’s room to check on her, and the orange magnet process used to indicate a resident was on the toilet or commode was not followed. Administrator A stated Resident 41 was distressed, upset, and had tears in her eyes when discussing the incident. The facility’s policy defined neglect as failing to provide goods or services a resident requires when the facility is aware of, or should have been aware of, the need, and Administrator A acknowledged the incident met that definition. The report further noted that the facility did not assess other residents’ call system cords to ensure they were functioning.
Failure to Educate Resident on Risks of Not Using Whirlpool Chair Safety Belt
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to use of a whirlpool tub chair safety belt. The facility had prior South Dakota Department of Health facility-reported incidents in which two residents fell when staff did not correctly use an assistive or safety device, including a whirlpool chair safety strap. The provider’s own Bath Chair Safety education stated that all residents are to use the bath chair strap unless the care plan reflects a refusal, and the whirlpool tub manufacturer’s manual required that all residents must always be securely safety belted at the waist when using the lift systems, warning that failure to secure the resident properly could result in injury. The resident at issue was admitted with diagnoses including Parkinson’s disease, diabetes, osteoarthritis, degenerative joint disease of the neck, and a history of an L2 compression fracture and falls. Her care plan documented that she was offered the whirlpool tub chair safety belt but may or may not use it, and she had hand tremors. Her BIMS score of 14 indicated intact cognition. There was no documentation in the electronic medical record that she had been assessed as not requiring the safety belt, and no documentation that she had been educated on the risks and potential adverse outcomes of not using the whirlpool safety belt. Staff interviews and observations showed that, in practice, all residents used the whirlpool chair safety belt except this resident. A CNA reported that all residents wore the safety belt unless the care plan indicated it was not required. The resident stated she used the whirlpool tub chair without the safety belt and reported she was not really aware that she could fall by not using it. The DON and administrator stated that the resident chose not to wear the safety belt and that this decision was reflected in her care plan, and the DON reported she had provided education about safe use of the safety belt, but there was no documentation of this education in the resident’s record, despite the manufacturer’s instructions that all residents must always be securely belted when using the whirlpool chair.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to five of eighteen sampled residents within 48 hours of their admission. This deficiency was identified through a review of electronic medical records, interviews, and policy reviews. For instance, one resident with severe cognitive impairment due to a stroke did not receive a baseline care plan until the fourth day of her stay. Another resident, who was cognitively intact, did not receive her baseline care plan until the twenty-fifth day of her stay, and the facility was unable to provide a printed copy as the resident had been discharged. The facility's policy required that a baseline care plan be developed within 48 hours of admission to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events. However, interviews with the director of social services and the administrator revealed that the facility did not consistently provide the baseline care plan summary to residents or their families within the required timeframe. The director of social services admitted to waiting three to four days after admission before providing the baseline care plan, which was contrary to the facility's policy. The deficiency was further highlighted by the facility's misunderstanding of the regulation regarding the timing of providing the baseline care plan summary. The administrator and director of nursing acknowledged that they had not provided all residents and/or families with the summary within 48 hours of admission. This lack of timely communication and documentation was evident in the cases of several residents, including those with significant medical conditions such as congestive heart failure, pneumonia, and diabetes mellitus, who did not receive their baseline care plans promptly.
Delayed Call Light Response for Two Residents
Penalty
Summary
The provider failed to maintain the physical, mental, and psychosocial well-being of residents by not ensuring prompt response to call lights for two residents. Resident 1 reported that it sometimes took staff 30-60 minutes to respond to her call light, resulting in incontinence of bowel and bladder due to the delay. Resident 16 also experienced significant delays, stating that staff blamed the call light system for the slow response, and she had waited over an hour on some occasions. Both residents had their call lights within reach and were cognitively intact, as indicated by their BIMS scores of 15. Call light audit reports for both residents showed numerous instances of response times exceeding 10, 20, and even 30 minutes, with the longest wait times being 72 minutes and 68 minutes for residents 1 and 16, respectively. The facility's policy aimed for a response time within 10 minutes 87% of the time, but this goal was not met. The director of nursing acknowledged that a 30-minute wait was excessively long and confirmed that all staff were responsible for answering call lights. Monthly audits were being conducted, but the delays persisted, indicating a failure to adhere to the facility's call light policy.
Failure to Monitor Nebulizer Treatment
Penalty
Summary
The provider failed to correctly administer medication to a resident by allowing her to self-administer a nebulizer treatment without a self-administration medication order. During an observation, a registered nurse (RN) set up the albuterol/ipratropium nebulizer treatment for the resident and handed her the nebulizer tube. The RN paused the treatment when the resident was on the phone and resumed it afterward, leaving the room without monitoring the resident during the treatment. Upon review, it was found that the resident did not have a self-administration medication order or evaluation documented in her electronic medical record (EMR), which was required before allowing self-administration. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had been admitted with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease. The director of nursing confirmed that residents must have a self-administration medication order to self-administer medications and agreed that the RN should have monitored the nebulizer treatment. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration, which were not completed for this resident.
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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