Avera Prince Of Peace
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux Falls, South Dakota.
- Location
- 4513 South Prince Of Peace Place, Sioux Falls, South Dakota 57103
- CMS Provider Number
- 435066
- Inspections on file
- 21
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avera Prince Of Peace during CMS and state inspections, most recent first.
A resident was discharged to another LTC facility without proper documentation that the transfer was necessary, and without providing required written notice or appeal information to the resident or their representative. The facility relied on a signed admission addendum as justification, but did not meet federal requirements for discharge documentation or notification.
A resident was discharged to another LTC facility without receiving the required 30-day written notice or information about appeal rights. The resident's representative was verbally informed of the discharge, but neither the resident, representative, nor the Ombudsman received written notification as mandated by facility policy.
Residents were not provided with information about the grievance process and experienced ongoing delays in call light responses, with staff sometimes failing to return or responding negatively. Concerns about housekeeping, such as catheter bins and bed linen changes, remained unresolved for several months despite being repeatedly raised in resident council meetings. The grievance process was not discussed at council meetings, and issues were not effectively resolved by management.
Surveyors found that staff repeatedly left computers displaying residents' medical information unattended and visible in hallways, resident rooms, and nurses' stations. Despite facility policy and staff expectations to lock or close screens when not present, multiple instances were observed where PHI was accessible to unauthorized individuals, resulting in breaches of confidentiality.
Multiple residents reported neglect due to prolonged call light response times, with some waiting over 10 minutes and experiencing pain, incontinence, and emotional distress. Residents described staff as rude, rough, or dismissive, and expressed fear or reluctance to request assistance. Complaints about staff behavior and delayed care were repeatedly raised in council meetings and individual interviews, with documentation showing unresolved issues and insufficient investigation or follow-up.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Staff did not consistently perform hand hygiene or use gloves properly while handling and serving food, including touching hair, face, and uniforms before serving meals, and failing to wear required hairnets. Food items were left uncovered and accessible, with residents touching food that was later served to others, in violation of facility policies.
Staff did not consistently use required PPE or perform hand hygiene during high-contact care activities for residents on enhanced barrier precautions, including those with indwelling devices, wounds, or infections. Multiple staff were observed providing care, handling soiled linens, and performing sterile procedures without following established infection control policies, leading to widespread noncompliance.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restrained their ability to function, in violation of regulations requiring the prevention of unnecessary drug use.
A resident with PTSD and bipolar 2 disorder, who was receiving related medications, had a completed PASRR Level II assessment that was not accurately documented in the MDS assessment. Staff interviews revealed that the PASRR Level II information was not properly entered, with the RN coordinator confirming inaccuracies in both comprehensive and quarterly MDS assessments, despite facility policy requiring accurate and complete documentation.
Surveyors identified that the facility failed to keep its medication error rate below 5%, with two errors out of twenty-seven observed administrations. One resident received carbidopa/levodopa late, and another received an underdose of Guaifenesin/DM SF, both administered by CMAs. The DON acknowledged the error rate, and the facility's policy defines these as medication errors.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
Failure to Ensure Proper Transfer/Discharge Procedures and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the transfer and discharge of a resident to another LTC facility met federal requirements. The resident, who was admitted to the rehabilitation area with a care plan goal to return home but with the understanding that a higher level of care might be needed, was discharged to another LTC facility approximately 75 miles away. The discharge was initiated after the care team determined the resident had not made sufficient progress in therapy and would require long-term care, which the facility stated could not be provided in the rehab unit. However, there was no documentation that the transfer was necessary for the resident's welfare, that the facility could no longer meet the resident's needs, that the resident's health had improved sufficiently, that the health or safety of others was endangered, or that the resident had failed to pay for their stay. Interviews with the resident's daughter revealed that the family was informed of the discharge only a few days prior and felt they were not given adequate time or notice to make alternative arrangements. The daughter also reported not being provided with information on how to appeal the discharge decision. The social worker confirmed that no written discharge notice or appeal information was given to the resident, their representative, or the ombudsman. The facility staff believed that the signed admission agreement addendum, which indicated the resident's consent to cooperate with discharge planning, was sufficient to proceed with the discharge without further documentation or notice. Review of facility policies and federal regulations showed that the facility's own policies required specific conditions to be met and documented for a transfer or discharge, including providing advance notice and information on appeal rights. Despite this, the facility did not provide evidence that any of the regulatory criteria for discharge were met in this case, nor did they follow the required notification and appeal procedures. The deficiency was identified through observation, interviews, record review, and policy review during the survey.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident, the resident's representative, and the Office of the State Long-Term Care Ombudsman at least 30 days prior to a planned transfer to another long-term care facility. The resident was admitted with a care plan goal to return home but was instead discharged to another facility approximately 75 miles away. Documentation in the electronic medical record did not show that the required written notice was given. The resident's daughter reported being verbally informed of the discharge six days prior but did not receive written notice or information about the right to appeal the decision. Interviews with the facility's social worker confirmed that no written discharge notice or appeal information was provided to the resident, the representative, or the Ombudsman. The social worker believed that the signed admission addendum allowed for discharge without the 30-day written notice and did not notify the Ombudsman until after the discharge occurred. Review of facility policies indicated that a 30-day written notice and information about appeal rights are required, but these procedures were not followed in this case.
Failure to Address Resident Grievances and Timely Response to Requests
Penalty
Summary
The facility failed to provide residents with information about the grievance process and did not ensure prompt or satisfactory resolution of concerns raised during resident council meetings. Multiple residents were unable to identify the facility grievance official, and the grievance process was not discussed at council meetings. Residents reported extended wait times for call light responses, with staff sometimes turning off call lights and not returning, or responding with negative attitudes and aggressive actions. Several residents expressed fear or humiliation when requesting assistance, and some experienced incontinence or pain due to delayed staff response. Concerns about housekeeping, such as catheter bins left in rooms and uncertainty about bed linen changes, were repeatedly raised but remained unresolved over several months. Review of resident council meeting minutes over several months showed that issues such as call light response times, catheter bins, and bed-making were consistently reported as unresolved. Management responses to these concerns were either delayed or insufficient, with some issues persisting for at least three months. The social services designee was unaware of the need to discuss the grievance process at council meetings and had not involved the area ombudsman. Grievances were handled by social services staff and forwarded to the ADON, but ongoing issues were simply referred to department heads without effective resolution.
Failure to Secure Electronic PHI Exposes Resident Information
Penalty
Summary
Surveyors observed multiple instances where residents' personal and medical information was left visible and unsecured on computer screens throughout several neighborhoods in the facility, including Bluegrass Way, Platinum Ridge, Boulder Creek, and Arrowhead Trail. Computers on rolling stands and at nurses' stations were found with screens open to sensitive resident information, such as medical records and medication lists, while unattended by staff. In several cases, the screens were positioned so that information could be viewed from the hallway, and it was not always clear which staff member was logged in at the time. These observations occurred both inside resident rooms and in common areas, with no staff present to monitor or secure the information. Interviews with staff, including an LPN, RN coordinator, and the DON, confirmed that the expectation was for computer screens to be closed or locked when not in use to protect resident privacy. The facility's policy on safeguarding protected health information (PHI) requires staff to log off or lock workstations when leaving the area and to position monitors to prevent unauthorized viewing. Despite these policies, staff failed to consistently secure electronic PHI, resulting in multiple breaches of confidentiality as observed by surveyors.
Failure to Protect Residents from Neglect and Delayed Response to Call Lights
Penalty
Summary
Residents experienced neglect related to delayed staff response to call lights, with multiple reports indicating that residents waited 10 minutes or longer, and in some cases up to 30 minutes or more, for assistance. Residents described being left in pain, feeling humiliated, and in some cases becoming incontinent while waiting for help. Several residents reported that staff would turn off call lights and either leave without assisting or promise to return but did not, and some staff responded with anger or rudeness when residents requested help, especially at night. These issues were consistently raised in resident council meetings and individual interviews, with residents expressing fear or reluctance to use their call lights due to negative staff reactions. Documentation from resident council meetings over several months showed that concerns about long call light response times and staff behavior remained unresolved. Residents repeatedly reported that staff were rough, rude, or dismissive, and that their complaints were not always addressed or investigated thoroughly. Specific incidents included residents being left in soiled clothing for extended periods, being spoken to harshly, and experiencing physical discomfort or injury due to delayed or rough care. Call light audits confirmed that several residents experienced frequent and prolonged waits for assistance, particularly during busy times such as mornings. The facility's complaint and grievance records revealed a pattern of similar concerns from both residents and staff, including reports of staff ignoring call lights, yelling at residents, and providing rough or disrespectful care. Investigations into these complaints often lacked clear identification of the staff involved and did not always include thorough documentation of follow-up or resolution. Staff interviews indicated that while education on resident rights and abuse was provided, there was no consistent process for monitoring or addressing ongoing concerns, and some staff attributed negative interactions to cultural differences rather than addressing the underlying issues of neglect and disrespect.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals. No further details about specific residents, staff, or incidents are provided in the report.
Failure to Follow Hand Hygiene and Food Safety Practices During Meal Service
Penalty
Summary
Staff failed to follow standard food safety practices during multiple observed meal services in two of three neighborhood dining rooms. Specifically, servers and certified medication aides (CMAs) did not consistently perform hand hygiene or use gloves appropriately while handling food and serving residents. Observations included staff touching their hair, face, uniforms, and other non-food surfaces, then handling food or serving utensils without washing their hands. Additionally, some staff did not wear required hairnets, and food items such as bread and pastries were left uncovered and accessible to both staff and residents, with instances of residents touching multiple food items before they were served to others. The facility's own policies required hand hygiene before clean procedures, after glove removal, and when handling ready-to-eat foods, as well as the use of hairnets in the kitchen. Despite these policies, staff were observed repeatedly failing to wash hands after removing gloves, after touching potentially contaminated surfaces, and before handling food. Interviews with staff confirmed a lack of awareness regarding proper hand hygiene and food handling protocols, contributing to the observed deficiencies.
Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
Staff failed to follow standard infection prevention and control practices for all sampled residents on enhanced barrier precautions (EBP). Observations revealed that staff, including certified medication aides, LPNs, RNs, and housekeepers, did not consistently wear required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. These activities included transferring residents, providing hygiene, changing linens, and device care for residents with indwelling devices, wounds, or infections. In several instances, PPE was not visible or accessible, and staff were observed performing care without donning appropriate protective gear, despite clear signage and policy requirements. Multiple staff members were observed not performing hand hygiene at critical moments, such as before and after resident contact, after glove removal, and before handling clean supplies or equipment. Staff were also seen using the same gloves for multiple tasks, touching clean supplies with contaminated gloves, and failing to clean equipment and personal items after use in EBP rooms. In some cases, staff expressed uncertainty about the reasons for EBP or the correct procedures for hand hygiene and PPE use, despite existing policies and posted instructions. Residents involved had significant risk factors, including indwelling urinary catheters, feeding tubes, wounds, and histories of multidrug-resistant organism (MDRO) infections or urinary tract infections. The facility's own policies required sterile technique for certain procedures, such as urinary catheter flushing, and mandated that soiled linens be bagged at the point of care. However, staff were observed using non-sterile containers for sterile solutions, transporting soiled linens without proper containment, and storing clean supplies inappropriately. Interviews with facility leadership confirmed expectations for compliance with infection control policies, but direct observations and staff interviews demonstrated widespread noncompliance.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Inaccurate PASRR Level II Coding on MDS Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASRR) Level II assessment was accurately coded on the Minimum Data Set (MDS) assessment. The resident, who had diagnoses of post-traumatic stress disorder (PTSD) and bipolar 2 disorder and was receiving medications for these conditions, had a PASRR Level II assessment completed as required. However, interviews with facility staff revealed that the PASRR Level II information was not properly documented in the MDS assessments. The social worker designee stated that while she completed the PASRR Level II assessments for her assigned unit, she did not document them in the MDS, leaving this responsibility to the RN coordinator. The RN coordinator confirmed that the resident's most recent comprehensive and quarterly MDS assessments were inaccurately marked and did not reflect the required PASRR Level II information, despite the resident having a qualifying diagnosis. Further review of facility policies indicated that all staff completing any portion of the MDS must sign to attest to its accuracy, and the assessment coordinator is responsible for ensuring accurate and complete MDS data is transmitted to CMS. The director of nursing confirmed the expectation for accurate MDS documentation. The facility's PASRR policy also requires individualized screening and appropriate documentation for residents with mental illness or intellectual disabilities. The failure to accurately code the PASRR Level II assessment on the MDS resulted in incomplete and inaccurate resident assessment documentation.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation. During observation of medication administration, two errors were identified out of twenty-seven opportunities, resulting in a 7.41% error rate. In one instance, a certified medication aide (CMA) administered carbidopa/levodopa to a resident at 7:55 a.m., despite the medication being ordered for 6:30 a.m. The CMA indicated that the night shift typically administered this medication, but on this occasion, it was delayed and given by the day shift. The medication was ordered to be given three times daily. In another instance, a different CMA administered an incorrect dose of Guaifenesin/DM SF to a resident. The ordered dose was 10 mL, but only approximately 8 mL was measured and given, despite the CMA verifying the amount and stating it was correct. The facility's medication administration policy requires medications to be given at the correct time and dose, and defines such failures as medication errors. The Director of Nursing acknowledged the medication error rate during the survey.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
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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