Bethany Home Sioux Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux Falls, South Dakota.
- Location
- 1901 South Holly Avenue, Sioux Falls, South Dakota 57105
- CMS Provider Number
- 435096
- Inspections on file
- 21
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bethany Home Sioux Falls during CMS and state inspections, most recent first.
A resident with severe cognitive impairment eloped from the facility after the front door was left unmonitored and unalarmed when the administrative assistant stepped away without notifying staff. The resident exited undetected and was later found at a community member's home. Staff interviews and record review confirmed that required monitoring procedures were not followed, resulting in a lapse in supervision and resident safety.
A deficiency was identified when an LPN did not assess a resident or notify the physician after a family member reported concerns of a possible GI bleed, despite facility policy requiring immediate action for such symptoms. The resident, who had multiple co-morbidities and a significant drop in hemoglobin, did not receive timely evaluation or escalation of care, resulting in delayed medical intervention.
The provider failed to serve adequate portions during a lunch meal, affecting all residents on the main menu. The menu specified eight ounces of beef & broccoli and four ounces of diced carrots, but Cook L served only three ounces and two ounces, respectively. Despite knowing the correct portions, Cook L did not follow them, and the dietary manager was unaware of this issue.
The facility failed to maintain cleanliness in its kitchen equipment, with a convection oven and steamer found in unsanitary conditions. Observations revealed baked-on grease and food particles in the oven, and limescale and scum buildup in the steamer. Interviews indicated a lack of proper cleaning knowledge and adherence to cleaning schedules, despite audits marking the equipment as clean.
A resident did not receive the required SNF ABN and NOMNC before the end of their Medicare skilled services. The deficiency was linked to a lack of proper completion of these forms by a social worker, with conflicting reports on whether adequate training was provided.
An RN failed to provide necessary care and medication to 25 residents during a shift, as confirmed by video footage and staff interviews. The RN was absent from the unit for over an hour and did not perform required blood sugar checks, medication administrations, and treatments, despite documentation indicating otherwise. The facility's investigation revealed neglect of residents' needs, violating the policy on prevention of abuse and neglect.
The facility failed to provide written notices of transfer or discharge and notify the ombudsman for two residents. The deficiency was due to a previous social worker not fulfilling these responsibilities, as discovered during an investigation. Interviews with staff revealed uncertainty about the completion of required notices.
A facility failed to provide a written bed-hold notice to a resident's representative during a transfer to the emergency department. The social worker verbally communicated the policy, but no written documentation was made. The resident's representative declined to hold the bed and collected the resident's belongings.
The facility failed to update care plans for two residents to reflect their current medical conditions. One resident's care plan did not include a focus on dementia despite a diagnosis, and another's care plan did not reflect the initiation of a blood thinner for Atrial fibrillation. Interviews confirmed the oversight, contrary to the facility's policy requiring timely updates for significant changes.
Failure to Monitor Exit Door Results in Resident Elopement
Penalty
Summary
A resident with severely impaired cognition, as indicated by a BIMS score of seven, was admitted to the rehabilitation unit following a hospitalization for syncope and collapse. The resident was assessed as having a moderate risk for elopement due to her mobility, though she had not previously verbalized a desire to leave. On the day of the incident, the resident became upset after a care conference with her family, during which concerns about her ability to return home independently were discussed. Later that day, the resident exited the facility through the front door without staff knowledge. The front door was supposed to be locked and alarmed automatically at a certain time, but prior to that, it was to be monitored by staff. At the time of the elopement, the administrative assistant responsible for monitoring the front door had stepped away to make copies and did not notify other staff to monitor the door in her absence. As a result, the door was left unmonitored and unalarmed, allowing the resident to leave undetected. Staff only became aware of the elopement when a community member called to report that the resident was at their home nearby. Interviews with staff confirmed that rounds were conducted every two hours or less, but no one responded to a door alarm because none was triggered. The facility's elopement procedure required that residents' whereabouts be known at all times, but this was not followed due to the lapse in monitoring the front door. The resident was later found safe and returned to the facility, but the incident revealed a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Assess and Notify Physician for Suspected GI Bleed
Penalty
Summary
A deficiency occurred when an LPN failed to follow facility policy and practice within the scope of licensure after a family member raised concerns about a resident potentially experiencing a gastrointestinal (GI) bleed, as evidenced by black, pasty stools. The LPN documented the family’s concern and attributed the symptoms to new medications but did not assess the resident, notify the physician, or contact on-call leadership staff, despite facility policy requiring immediate physician notification for bleeding or bloody stools not due to hemorrhoids. There was no documentation of an assessment or escalation of the concern on the evening the issue was reported. The resident involved had multiple co-morbidities, including osteomyelitis, long-term anticoagulant use, diabetes with polyneuropathy, peripheral vascular disease, congestive heart failure, hypertension, and atrial fibrillation. Upon admission, the resident was alert, oriented, and had stable vital signs, receiving IV antibiotics and regular lab monitoring. Lab results showed a significant drop in hemoglobin over several days, and the resident was dependent on staff for toileting. Despite the family’s report of black, tarry stools, there was no documentation of such findings in the medical record, and the required assessment and physician notification were not performed promptly. Interviews with other nursing staff and the DON confirmed that the expected protocol was to assess the resident and notify the physician or on-call leadership when concerns were raised by family members. The facility’s policy specified immediate physician notification for suspected GI bleeding. The LPN’s failure to assess the resident and escalate the concern as required led to a delay in appropriate medical intervention and contributed to the identified deficiency.
Inadequate Portion Sizes Served During Lunch
Penalty
Summary
The provider failed to ensure that adequate portions were served according to the menu during a lunch meal, which had the potential to affect all residents receiving the main menu in the facility. On 11/7/24, the menu for lunch included beef & broccoli with a serving size of eight ounces and diced carrots with a serving size of four ounces. However, during the lunch service, Cook L served only three ounces of beef & broccoli and a heaping two ounces of diced carrots, despite the availability of the correct serving utensils. Cook L was aware of the serving sizes on the printed menu but chose not to use the correct portions without providing a reason. The dietary manager, G, was unaware that incorrect portion sizes were served and acknowledged the importance of following the approved menu to meet residents' dietary requirements.
Failure to Maintain Cleanliness in Kitchen Equipment
Penalty
Summary
The facility failed to maintain cleanliness in its kitchen equipment, specifically a Vulcan brand convection oven and a Cleveland brand SteamChef steamer. During an initial kitchen tour, it was observed that the convection oven was heavily coated in baked-on grease and food particles, while the steamer had an excessive buildup of limescale and scum, with food particles sitting in standing water at the bottom of the basin. These observations indicate a lack of adherence to proper cleaning protocols and standards for kitchen equipment maintenance. Interviews with the kitchen staff revealed further issues contributing to the deficiency. A cook admitted to cleaning the equipment daily and deep-cleaning weekly, but acknowledged that the equipment had not been deep-cleaned in about a month and was unaware of the proper cleaning steps for the steamer. The dietary manager confirmed the existence of a cleaning schedule and monthly audits for kitchen cleanliness but was unaware of the equipment's dirty condition and also did not know the proper cleaning steps for the steamer. A review of the provider's monthly kitchen cleanliness audits showed that the ovens and steamer were marked as clean and in good repair, despite the observed conditions. Additionally, the manufacturer's cleaning guidelines for the steamer recommended daily descaling to prevent mineral buildup, which was not being followed.
Failure to Provide Required Medicare Notices
Penalty
Summary
The provider failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for one of the sampled residents who received Medicare Part A skilled services. Specifically, Resident 247 did not receive the SNF ABN form CMS-10055 or NOMNC form CMS-10123 before the end of their Medicare skilled services on 9/23/24. This oversight was identified during a review of the provider's documentation and was attributed to a lack of proper completion of these forms by the previous social worker (SW) O. Interviews conducted with SW O and SW P revealed conflicting accounts regarding the training provided on completing the ABNs. SW O reported not receiving training upon hiring, while SW P claimed to have provided the necessary training. This discrepancy contributed to the failure in issuing the required notifications to Resident 247, leading to the identified deficiency.
RN Fails to Administer Care and Medications to Residents
Penalty
Summary
The report details a significant deficiency involving a registered nurse (RN) identified as RN F, who failed to provide necessary care and medication administration to 25 residents during a twelve-hour shift. On the specified date, RN F was absent from her unit for a period of time and was unaccounted for by the staff. During her shift, RN F was observed on video footage leaving the unit and not returning for over an hour and a half. Despite being reminded by a certified nursing assistant (CNA) to administer morning narcotics to three residents, RN F did not visibly enter the residents' rooms to provide the medications, although they were signed off as administered. The facility's investigation revealed that RN F did not perform the required blood sugar checks, medication administrations, and treatments for the residents under her care. The video footage confirmed that RN F did not enter the rooms of the residents to provide the documented care. The residents were supposed to receive various treatments, including pain management patches, insulin administration, blood sugar checks, and other medications, which were not carried out as per the orders. The documentation by RN F indicated that these tasks were completed, but the investigation and video evidence contradicted this. The director of nursing (DON) confirmed through interviews with other staff and video review that RN F did not provide the necessary care to the residents. The facility's policy on the prevention of resident abuse, neglect, and misappropriation of property was not adhered to, as RN F's actions constituted neglect of the residents' needs. The video surveillance footage that could have further substantiated these findings was not made available for survey review during the investigation.
Failure to Provide Required Transfer Notices
Penalty
Summary
The provider failed to provide a written notice of transfer or discharge and to notify the ombudsman for two residents. The deficiency was identified during an interview and record review, which revealed that the previous social worker did not provide the required written notices for transfers or discharges. Specifically, one resident was transferred to the local emergency department on two occasions, and another resident was transferred once, with no documentation of the required notices or ombudsman notification for any of these instances. The issue was discovered when the facility's management team conducted an investigation after noticing a lack of documentation for required notices. The investigation revealed that the previous social worker was responsible for the oversight. Interviews with staff, including a nurse manager, indicated uncertainty about whether the notices were completed correctly due to the previous social worker's actions.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The provider failed to provide a written bed-hold notice to a resident or their representative when the resident was transferred to the emergency department. This deficiency was identified during an interview and record review, which revealed that the previous social worker responsible for issuing these notices did not provide the required written documentation. Specifically, for one resident, although the social worker verbally communicated the bed-hold policy to the resident's representative, there was no written notice documented. The resident's representative declined to hold the bed and collected the resident's belongings from the facility. The deficiency was discovered when the facility's management team conducted an investigation into the lack of documentation for various required notices. The investigation revealed that the former social worker had not been providing the necessary written notices, including bed-hold notices. This issue was identified as part of a broader problem with documentation that the facility addressed through corrective actions.
Care Plan Updates Not Reflecting Residents' Current Conditions
Penalty
Summary
The provider failed to ensure that the care plans for two residents were updated to reflect their current medical conditions. Resident 11 was diagnosed with dementia and other diseases on August 6, 2024, and was prescribed Seroquel for Major Depressive Disorder on August 15, 2024. However, the care plan updated on August 20, 2024, did not include a focus area for the resident's dementia diagnosis, only noting the use of psychotropic medications for pain management and depression. Similarly, Resident 25 was prescribed Apixaban for Atrial fibrillation on August 23, 2024, to prevent blood clots. Despite this, the care plan updated on October 29, 2024, failed to reflect the initiation of Apixaban. Interviews with the director of nursing, nurse manager, and administrator confirmed that the care plans for both residents had not been updated to meet their care needs. The facility's policy requires care plans to be updated with significant changes, but this was not adhered to in these cases.
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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