Bethany Home - Brandon
Inspection history, citations, penalties and survey trends for this long-term care facility in Brandon, South Dakota.
- Location
- 3012 E Aspen Blvd, Brandon, South Dakota 57005
- CMS Provider Number
- 435130
- Inspections on file
- 25
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Bethany Home - Brandon during CMS and state inspections, most recent first.
A CNA/CMA engaged in verbal abuse and neglect by withholding fluids, denying requests for beverages, yelling, and attempting to force-feed several residents in a memory care unit. These actions caused distress and agitation among cognitively impaired residents, and were corroborated by staff observations and interviews.
Multiple residents sustained serious injuries after CNAs failed to use whirlpool bath chair safety belts as required and did not follow care plan instructions for mechanical lift transfers. In two cases, residents fell from bath chairs after the safety belt was removed and staff turned away, resulting in fractures and hospitalization. In another case, a resident was transferred alone with the wrong lift device, leading to a leg fracture. Staff interviews and records confirmed that safety protocols were not followed despite prior training.
A resident with a history of falls and moderate cognitive impairment fell forward from her wheelchair and sustained a head laceration requiring sutures when staff transported her without the required wheelchair foot pedals in place. Staff interviews and record review confirmed that the facility's policy mandated the use of foot pedals for wheelchair users, but the pedals were not attached at the time of the incident, leading to the resident's injury.
Two residents with severe cognitive impairment experienced abuse and neglect by CNAs: one was subjected to aggressive handling and verbal abuse during care, while another was left on a bedpan for an extended period, resulting in a skin injury. Both incidents involved failure to follow care plans and required interventions for dependent residents.
A nurse failed to properly document the administration of controlled medications for a resident, leaving medications unattended and incorrectly recording doses of lorazepam and oxycodone. Discrepancies were found between medication cards, controlled drug records, and the MAR, with some doses not documented or signed out as required. These actions resulted in inaccurate records and a lack of proper accountability for controlled substances.
The facility failed to maintain proper sanitation practices in the kitchen and neighborhood kitchenettes, with expired sanitizer test strips and inconsistent dishwasher temperature logs. Additionally, a CNA was observed handling a resident's food with bare hands, contrary to policy. These deficiencies increased the risk of foodborne illnesses for residents.
The facility failed to ensure proper oversight in the food and nutrition services department, as the dietary director was unaware of nursing home kitchen regulations and no food service audits were conducted. The consultant dietitian's visits were undocumented, and the dietary director's responsibilities, including policy development and kitchen maintenance, were not fulfilled. This lack of oversight increased the risk of foodborne illnesses for residents.
The facility failed to maintain privacy and obtain consent for audio and video monitoring devices in residents' rooms. Observations revealed that 13 residents had monitoring devices without proper signage or consent, compromising privacy. Several residents were unaware of the devices, and their EMRs lacked documentation of consent or care plan updates. Staff were not adequately informed about the devices, and the facility's privacy policy did not address their use.
The facility failed to implement an effective grievance process, compromising residents' rights to file grievances and have them addressed. Issues included lack of documentation, investigation, and follow-up on grievances, as well as outdated policies and no formal tracking system. Residents reported unresolved concerns about food quality and missing personal items, while staff interviews revealed inconsistencies in handling grievances.
The facility failed to accurately code MDS assessments for two residents using seat belts in their wheelchairs. One resident, with intact cognition, used a seat belt daily by choice, while the other, moderately cognitively impaired, rarely used it. Observations and interviews revealed discrepancies in MDS coding, with the director of nursing confirming the seat belts were coded as restraints, despite stating they were not used as such.
A CNA suspected of being intoxicated was allowed to work a weekend shift without thorough investigation by the facility. Despite staff reports of strange behavior and the smell of alcohol, the CNA continued working until termination the following Monday. The facility's failure to enforce its policies on alcohol use and conduct a timely investigation represents a deficiency.
Failure to Protect Residents from Verbal Abuse and Neglect by CNA/CMA
Penalty
Summary
The facility failed to protect multiple residents from verbal abuse and neglect by a certified nurse aide/certified medication aide (CNA/CMA). The incident involved the CNA/CMA withholding fluids from residents during meals as a form of punishment for making a mess or for concerns that they would not eat if given drinks. Additionally, the CNA/CMA denied a resident's repeated requests for coffee, yelled at residents, and attempted to force-feed residents by shoving large bites of food into their mouths while yelling at them to eat. These actions caused distress and agitation among the residents, particularly those with significant memory and cognitive decline residing in a secured memory care unit. The report details that the CNA/CMA also scolded a resident for wanting to change her clothes frequently, attributing it to creating extra work and laundry for staff. Staff interviews and record reviews confirmed that these behaviors were observed and reported by another CNA/CMA, and additional staff corroborated the allegations. The affected residents included those with cognitive impairments who were particularly vulnerable to such treatment, and the incidents occurred in a specialized memory care neighborhood designed to provide a structured and supportive environment. Prior to the incident being reported, there were no documented concerns or disciplinary actions related to the CNA/CMA's care or treatment of residents, aside from previous medication administration errors. The deficiency was substantiated through staff interviews and review of the facility's records, which confirmed that the residents were subjected to verbal abuse and neglect by the CNA/CMA during the provision of care.
Failure to Follow Safety Protocols During Bathing and Transfers Resulting in Resident Injuries
Penalty
Summary
Certified nursing assistants (CNAs) failed to follow established safety protocols during resident bathing and transfers, resulting in serious injuries to multiple residents. In two separate incidents, CNAs removed the whirlpool bath chair safety belt before the residents were ready to be transferred, leaving the residents unsecured. In one case, a CNA turned away from a resident after removing the safety belt to retrieve nail clippers, and the resident fell forward out of the bath chair, sustaining a pelvic fracture. In another case, a CNA removed the safety belt to dry a resident and turned away, leading to the resident falling out of the chair and suffering multiple fractures, including to the spine, pelvis, and tibia. Both residents required hospitalization for their injuries. Additionally, a CNA failed to follow the care plan for a resident requiring transfer with a mechanical total lift and assistance from two staff members. Instead, the CNA transferred the resident alone and used the incorrect lift device, contrary to the resident's care plan and facility policy. This resulted in the resident sustaining an acute fracture of the proximal tibia in her lower left leg. The injury was discovered later when a bruise was noted, and subsequent assessment and imaging confirmed the fracture. The resident was under hospice care at the time of the incident. Interviews and observations confirmed that staff were aware of the facility's policies requiring the use of safety belts during bathing and the need for two staff members during mechanical lift transfers. Documentation showed that the involved CNAs had previously received training on these procedures. Despite this, the protocols were not followed, directly leading to the residents' injuries during routine care activities.
Failure to Ensure Use of Wheelchair Foot Pedals Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, traumatic subdural hemorrhage, and moderate cognitive impairment fell from her wheelchair and sustained a laceration to her forehead that required sutures. The incident took place when the resident was being transported in her wheelchair without the required foot pedals in place, contrary to facility policy. The absence of the foot pedals caused the resident to fall forward out of the wheelchair, resulting in injury. Record review showed that the resident had a care plan identifying her as being at risk for falls, with multiple falls reported in the previous six months, including one that led to her current admission. On the day of the incident, staff responded to a call for help and found the resident on the floor, bleeding from her forehead. The injury could not be controlled with pressure, and the resident was transported to the emergency department, where she received sutures before returning to the facility. Interviews with staff revealed that the use of wheelchair foot pedals was expected and outlined in facility policy, which required pedals to be used unless otherwise care planned. However, at the time of the incident, the pedals were not attached to the resident's wheelchair. Staff acknowledged awareness of the importance of using foot pedals, and the director of nursing confirmed that no formal monitoring mechanism was in place to ensure compliance with this requirement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A cognitively impaired resident residing in a secured memory care unit, who was dependent on staff for activities of daily living and known to be resistive to care, was subjected to verbal and physical abuse by a certified nursing assistant (CNA). The CNA became frustrated while assisting the resident with undressing, aggressively removed the resident's arm from his sweatshirt, and attempted to pry the shirt from his hands, causing the resident to verbally express pain. The incident was witnessed by another staff member, who reported discomfort with the CNA's actions and observed a change in the CNA's demeanor upon realizing she was being watched. The resident had severe cognitive impairment and was unable to be interviewed about the incident. In a separate incident, another cognitively impaired resident who required total staff assistance for toileting and repositioning was left on a bedpan for an extended period of time by a CNA. The resident was unable to reposition herself and was found with linear, slow-to-blanch marks on her buttock, consistent with prolonged pressure from a bedpan. Documentation and staff interviews confirmed that the resident had been placed on the bedpan during the night shift and was not removed until discovered by day shift staff several hours later. The resident's care plan required frequent repositioning and total assistance with toileting, which was not provided as required. Both incidents involved residents with significant cognitive impairment and dependency on staff for care. In the first case, the resident's care plan included specific interventions for resistance to care, such as reassurance and re-approaching after a short interval, which were not followed. In the second case, the failure to remove the resident from the bedpan in a timely manner resulted in a skin injury. The events were substantiated through staff interviews, record reviews, and direct observation, demonstrating failures to protect residents from abuse and neglect.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
A deficiency occurred when a nurse failed to correctly document the administration of controlled medications for a resident. Specifically, the nurse left controlled medications unattended on top of a medication cart and incorrectly signed out three doses of lorazepam on the controlled drug record, while the actual medication card count did not match the documentation. Additionally, the nurse signed out doses of oxycodone on the medication administration record (MAR) but did not document the administration of lorazepam in the MAR, and a scheduled lorazepam dose was documented at a different time. There were also discrepancies in the narcotic count sheets for both lorazepam and oxycodone, with mismatched counts between the medication cards and the controlled drug records. Further review revealed that another nurse administered a dose of oxycodone but failed to sign it out on the controlled drug record. During shift changes and narcotic counts, discrepancies were noted, and requests to correct the narcotic records were not immediately addressed. The nurse responsible for the errors admitted to incorrectly signing out doses and not documenting medication administration in the MAR. These actions and inactions led to inaccurate records and discrepancies in the accountability of controlled substances for the resident.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation practices in the main kitchen and neighborhood kitchenettes, leading to potential risks of foodborne illnesses for residents. Observations revealed that staff were unable to verify the chemical sanitation levels required for cleaning kitchen surfaces, as the sanitizer test strips were expired and not used. Additionally, there was no system in place to document the testing of sanitizer solutions, and the dishwasher temperatures were not consistently recorded, with some rinse cycles failing to meet the manufacturer's required minimum of 180 degrees Fahrenheit. In the neighborhood kitchenettes, the dishwashers were not consistently reaching the required rinse temperature of 180 degrees Fahrenheit, as specified by the manufacturer's manual. Maintenance staff were responsible for overseeing the dishwashers but did not keep logs of temperature checks, and the dishwashers were only monitored about once every three weeks. This lack of consistent monitoring and documentation increased the risk of unsanitary dishware being used for resident meals. Furthermore, a hospice CNA was observed assisting a resident with eating a sandwich using bare hands, contrary to the facility's policy that required the use of gloves or utensils when handling ready-to-serve foods. The CNA later acknowledged the mistake and received additional training. The facility's director of nursing confirmed that the CNA should have worn gloves, highlighting a lapse in adherence to food handling protocols.
Deficiency in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure that the dietitian and dietary director effectively carried out the functions of the food and nutrition services department. This failure was identified through observation, interviews, record reviews, and job description reviews. The dietary director, who had been in her position for two months, was not aware of the regulations applicable to nursing home kitchens and had not seen the necessary policies until the survey week. Additionally, there were no food service-related audits conducted since she started. The consultant registered dietitian visited weekly but did not record these visits, although documentation was made in residents' medical records. The dietary director's position description outlined responsibilities such as consulting with the dietitian, maintaining a clean kitchen environment, and developing policies in compliance with food service regulations. However, these responsibilities were not fulfilled, as evidenced by the lack of oversight in cleaning, sanitization, and record-keeping in the main kitchen and four kitchenettes. The contract for registered dietitian services was not signed by the current facility administrator, and the maintenance director's position description did not include oversight of the kitchenettes or monitoring of dishwasher temperatures. This lack of oversight increased the potential risk of foodborne illnesses for residents receiving meals from these areas.
Failure to Maintain Privacy and Obtain Consent for Monitoring Devices
Penalty
Summary
The deficiency report highlights the failure of the provider to maintain privacy and obtain consent for the use of audio and video monitoring devices in residents' rooms. Observations and interviews revealed that 13 residents had monitoring devices in their rooms, but there was no signage indicating their presence, and consent was not obtained for six of these residents. The devices were used for monitoring purposes, such as fall prevention, but the lack of consent and signage compromised residents' privacy. Several residents were unable to identify the monitoring devices in their rooms, and there was no documentation in their electronic medical records (EMR) indicating that consent had been obtained or that care plans had been updated to reflect the use of these devices. For instance, resident 13's EMR lacked documentation of consent, and the care plan was not updated. Similarly, resident 106 had an audio device in their room without consent or care plan updates, and the device was later removed without explanation. The report also notes that the facility's staff, including newly hired employees, were not adequately informed about the presence and use of these monitoring devices. Interviews with staff members revealed a lack of awareness and training regarding the devices, and the facility's privacy policy did not specifically address the use of monitoring devices. The absence of a formal consent process and the failure to post notices about the monitoring devices contributed to the deficiency in maintaining residents' privacy and confidentiality.
Failure to Implement Effective Grievance Process
Penalty
Summary
The facility failed to implement an effective grievance process, which compromised the residents' right to file grievances and have them addressed appropriately. The provider did not ensure that all written grievance decisions included essential details such as the date the grievance was received, a summary of the grievance, steps taken to investigate, findings, conclusions, and any corrective actions. Additionally, the facility did not maintain grievance documentation for the required period of three years, nor did it make prompt efforts to resolve grievances or keep residents informed of progress. Interviews with residents and staff revealed multiple instances where grievances were not documented or followed up on. Resident 20 expressed ongoing concerns about the quality of food, which were voiced to staff, at resident council meetings, and during care plan conferences, yet remained unaddressed. Similarly, resident 41's husband reported a missing bag of personal items and concerns about the quality of fish served, but these issues were not formally documented or resolved. Staff interviews indicated a lack of clarity and consistency in handling grievances, with some staff not filling out grievance forms for reported concerns. The facility's grievance policy was outdated, and there was no formal grievance tracking system in place. The social services director was unaware of the updated grievance policy and continued to use an outdated form. The life enrichment director documented resident concerns during council meetings but did not fill out grievance forms or receive consistent responses from department directors. The administrator confirmed the absence of a grievance log and formal grievances, indicating a systemic failure to document and address resident grievances effectively.
Inaccurate MDS Coding for Wheelchair Seat Belts
Penalty
Summary
The provider failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents who used seat belts in their wheelchairs. Resident 23, who had intact cognition, used a seat belt on her electric wheelchair by choice and could independently apply and remove it. However, her MDS inaccurately coded the trunk restraint as not used, despite an edit note indicating daily use of the seat belt. Her care plan and restraint assessment confirmed her ability to manage the seat belt independently and her preference for its use for safety. Resident 32, who was moderately cognitively impaired, had a seat belt for wheelchair positioning but rarely used it. Observations showed the seat belt was not fastened, and the resident was unsure of its purpose or her ability to use it. Her MDS inaccurately coded the trunk restraint as not used, with an edit note stating she could remove it herself, although she rarely did. The director of nursing confirmed the seat belts were coded as restraints on the MDS, despite stating they were not used as restraints.
Failure to Investigate Alleged Intoxication of CNA
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a certified nursing assistant (CNA) suspected of being intoxicated while on duty. The incident occurred when staff reported that the CNA was acting strangely and smelled of alcohol during her shift. Despite these concerns, the CNA was allowed to continue working the following weekend without any follow-up investigation by the administration. The police were contacted, but they did not conduct a breathalyzer test as they did not find sufficient evidence of intoxication. The Director of Nursing (DON) was informed of the situation but did not take immediate action to investigate further or remove the CNA from the schedule. The CNA was eventually terminated on the following Monday after a container smelling of alcohol was found in the staff break room. However, the facility's failure to act promptly and investigate thoroughly left residents at risk during the weekend when the CNA continued to work. Interviews with other staff members revealed that they were unaware of any alcohol use in the facility, and the CNA in question had not been seen consuming alcohol. The facility's employee handbook outlines strict policies against working under the influence of alcohol, but these policies were not effectively enforced in this instance. The lack of immediate and thorough investigation into the allegations of intoxication represents a deficiency in the facility's handling of the situation.
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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