Dells Nursing And Rehab Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dell Rapids, South Dakota.
- Location
- 1400 Thresher Dr, Dell Rapids, South Dakota 57022
- CMS Provider Number
- 435129
- Inspections on file
- 26
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Dells Nursing And Rehab Center Inc during CMS and state inspections, most recent first.
A resident with diabetes and orthostatic hypotension did not receive blood pressure medications according to physician-ordered parameters. Midodrine and Fludrocortisone were both administered outside of the specified blood pressure ranges, and low blood pressures were not promptly rechecked. CMAs involved were unaware of the facility's blood pressure policy, and required notifications and documentation were not completed as per facility protocols.
The facility did not use current Medicare notification forms or fully complete required information when informing three residents and their representatives about the end of Medicare Part A skilled services. Outdated NOMNC and SNF ABN forms were used, missing key details such as the type of services ending and QIO contact information. Two of the affected residents had severe cognitive impairment, and one had moderate impairment. The social services designee was unaware of the updated requirements and did not document all necessary information during phone notifications.
Surveyors found that staff did not consistently use PPE during high-contact care for residents on enhanced barrier precautions, and urinary catheter care practices were not in line with facility policy, with reused and improperly stored catheter bags and unlabeled supplies. Several CNAs were unfamiliar with updated infection control policies, and documentation of staff education was incomplete. The facility also lacked comprehensive written policies for infection surveillance, communicable disease reporting, and isolation precautions, and expired or unlabeled medical supplies were found in storage areas.
A facility failed to implement and monitor care plans for pressure ulcer prevention, leading to the development of ulcers in three residents. One resident developed a heel ulcer due to delayed use of Prevalon boots, while another had a stage II ulcer without proper cushion support. A third resident had open areas on his buttocks without adequate pressure reduction interventions. The facility lacked documentation and staff training on pressure ulcer care.
The facility inaccurately submitted PBJ data for a federal fiscal quarter, showing no licensed nursing coverage on certain days, despite records indicating otherwise. The administrator, responsible for PBJ submission, was unaware of the discrepancies and speculated manual entry errors might be the cause, though some missing coverage days were not staffed by agency staff.
The facility failed to implement enhanced barrier precautions (EBP) and proper infection control practices. Observations showed a lack of PPE, improper hand hygiene, and expired products in resident care areas. Staff interviews revealed insufficient training and awareness of EBP protocols and infection control measures.
A LTC facility failed to update care plans for several residents, leading to deficiencies in care. Residents experienced falls, pressure ulcers, UTIs, and elopement risks without appropriate updates to their care plans. The facility's care planning process did not consistently reflect residents' changing needs and conditions.
The facility failed to secure chemicals properly, with observations showing unlocked cabinets and rooms containing various chemicals, some outdated or improperly labeled. Staff interviews revealed a lack of awareness and adherence to chemical storage policies, despite clear instructions and expectations for secure storage.
A facility failed to prevent significant medication errors, including a resident receiving another's medications, a non-diabetic resident given insulin, and a resident administered a discontinued medication. These errors highlight lapses in medication verification and staff training.
A resident with severe cognitive impairment experienced significant weight loss due to inadequate monitoring and documentation of meal consumption. Despite requiring assistance with eating, the resident was not consistently encouraged or assisted during meals, and meal intake was poorly documented. The care plan did not address the resident's weight loss, and there was a lack of hydration documentation, contributing to the deficiency.
The facility failed to implement an effective antibiotic stewardship program, leading to repeated antibiotic prescriptions for a resident with chronic UTIs without proper documentation or decision-making tools. Staff inconsistencies in obtaining and documenting orders for urine tests were noted, and the infection preventionist's tracking was limited to a spreadsheet. The facility's infection control policy was not effectively implemented, resulting in multiple residents being prescribed antibiotics without clear lab-confirmed infections.
A controlled medication, morphine sulfate, was not properly secured or accounted for in a facility. RN D did not perform the required narcotic count with LPN R at the end of her shift, leading to the discovery of missing medication the following day. Nurse manager C and the pharmacy investigated the incident, revealing a failure to adhere to the facility's Narcotic Count Policy.
The facility failed to report missing controlled medication, specifically morphine sulfate, to the SD DOH in a timely manner. The nurse manager and administrator were unaware of the reporting timeline and did not follow the facility's policy for reporting potential diversion of controlled substances. The incident was discovered on November 24, but the FRI was not submitted until December 4, highlighting a deficiency in timely reporting and adherence to protocols.
A resident with moderate cognitive impairment eloped from the facility after a door alarm was turned off and not reactivated. The resident was found outside, having left the dining room unnoticed. The incident revealed a lapse in safety protocols related to door alarm management.
A resident's bruise of unknown origin was not reported or investigated according to the facility's policy. The LPN failed to document the bruise, notify the family and physician, or report it to the charge nurse or DON. The DON and administrator acknowledged the lapse in procedure, which was not monitored recently, leading to the deficiency.
The facility failed to maintain the dishwasher, resulting in food scum and limescale buildup. Observations showed the dishwasher had not been cleaned or delimed regularly, with staff unaware of the cleaning schedule. The last recorded deliming was two months prior, contrary to the facility's policy requiring regular maintenance.
A facility failed to report a resident's abnormal blood sugar levels to the doctor as required by the physician's orders. Additionally, a prescription ointment was improperly stored at a resident's bedside without a physician's order or assessment, contrary to the facility's policy. Staff interviews confirmed these deficiencies.
The facility failed to serve adequate portion sizes during a lunch service, with Cook H using incorrect scoop sizes for taco bake, resulting in servings that were less than the menu requirements. Cook H was unaware of the correct portion sizes, and the acting dietary manager was not informed of the issue.
Failure to Administer Blood Pressure Medications per Physician Orders
Penalty
Summary
The provider failed to ensure that blood pressure medications were administered according to physician orders for a resident with diagnoses of type 2 diabetes, orthostatic hypotension, and weakness. Upon admission, the resident had specific orders for Midodrine and Fludrocortisone, both with hold parameters based on systolic blood pressure (SBP) readings. Review of the Medication Administration Record (MAR) revealed that Midodrine was administered six times when the resident's SBP was above the ordered threshold, and was not given five times when the SBP was low and the medication should have been administered. Fludrocortisone was also administered twice when the SBP was above the hold parameter. In addition, low blood pressures were not rechecked until the following day when Midodrine was held, contrary to expectations. Interviews with the Director of Nursing (DON) and Certified Medication Aides (CMAs) confirmed that the staff responsible for administering the medications did not consistently follow the blood pressure hold parameters. The DON acknowledged that the facility's policy required blood pressure to be checked prior to administration and that the physician should be notified if readings were out of parameters. The CMAs involved were not aware they had administered medications outside of the prescribed parameters and were unfamiliar with the facility's Blood Pressure Parameter Policy and notification requirements. Review of job descriptions and facility policies indicated that CMAs and RNs were responsible for observing and reporting symptoms, taking and recording vital signs, and notifying the charge nurse of medication errors. The facility's policies also required that medication errors be reported, the physician and DON notified, and the resident monitored for 24 hours following an error. Despite these policies, the required procedures were not followed, resulting in multiple medication administration errors for the resident.
Failure to Provide Proper and Updated Medicare Coverage Notices
Penalty
Summary
The provider failed to ensure that proper Medicare notices were completed fully and in the required format for three sampled residents prior to their discharge from Medicare Part A skilled services. Specifically, the facility used outdated versions of the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms, despite updated forms being mandated for use as of specific dates. The NOMNC forms did not specify the type of services ending, such as skilled nursing, and lacked required contact information for the Quality Improvement Organization (QIO), including the name and toll-free number. Additionally, the forms did not include all information required when notice was delivered by phone to a resident's representative, such as the last day of covered services, the date liability would begin, and details about the appeal process. The sampled residents included two who remained in the facility after their Medicare Part A coverage ended and one who was discharged home. Among these, two residents had severe cognitive impairment and one had moderate cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. The facility's social services designee (SSD) completed the forms and contacted the residents' representatives by phone, but failed to document all required information on the forms and did not mail annotated copies to the representatives as required. During an interview, the SSD acknowledged being unaware that the forms used were outdated and that new forms were required. The SSD also agreed that the forms were not fully completed according to instructions, including missing information about the type of services ending and the QIO contact details. The SSD was not aware of the specific documentation requirements for telephone notification to representatives, resulting in incomplete records for the residents affected.
Deficient Infection Control Practices and Incomplete Policy Implementation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility’s infection prevention and control practices, particularly regarding the use of enhanced barrier precautions (EBP) and urinary catheter care. Certified nursing assistants (CNAs) were observed failing to consistently wear appropriate personal protective equipment (PPE) when providing care to residents on EBP, such as not donning gowns during high-contact activities like transfers. In one instance, a CNA transferred a resident with open wounds without wearing a gown, despite EBP signage and CDC guidance posted in the facility. Additionally, staff did not always perform hand hygiene after removing PPE or before assisting residents with personal items. The facility’s practices for urinary catheter care and storage were inconsistent with policy and infection control standards. Catheter collection bags were reused, stored in plastic trash bags tied to towel racks, and not always labeled or dated. Staff described and demonstrated cleaning procedures that varied from the written policy, including the use of an incorrect vinegar-to-water ratio for cleaning solutions and leaving cleaning solution in bags for extended periods. Supplies such as normal saline and syringes were found opened, unlabeled, and not properly stored or disposed of in resident rooms and supply areas. Several CNAs were unfamiliar with the revised catheter care policy, and documentation of staff education on new policies was incomplete. The facility’s infection prevention and control program lacked comprehensive written policies and procedures in several required areas. There was no documented system for infection surveillance, reporting communicable diseases, determining the duration and restrictiveness of isolation precautions, or prohibiting staff with communicable diseases from resident contact. The policies provided did not address these elements, and staff interviews confirmed the absence of written guidance, relying instead on verbal instructions or external resources. Expired and unlabeled medical supplies were also found in storage areas, further indicating lapses in infection control practices.
Failure to Implement and Monitor Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and monitor care planned approaches for a resident identified on admission as having potential for pressure ulcer development, leading to the development of a heel pressure ulcer. The resident was admitted for strengthening due to a urinary tract infection and had a black spot on her left heel that was not present upon admission. Despite standing orders for Prevalon boots for pressure ulcer prevention, the resident did not start using them until after the sore developed. The care plan was not revised once the skin alteration was identified, and there was a lack of documentation regarding the skin alteration on admission. Two other residents acquired pressure ulcers after admission due to inadequate implementation and monitoring of care plan approaches. One resident had a stage II pressure ulcer on her left hip, but the care plan was not updated to include the use of pressure-reduction devices like the ROHO cushion. The cushion was not inflated, and there was no cushion in the resident's recliner. The facility's staff were not adequately trained on the use and maintenance of the ROHO cushions, and the care plan lacked documentation of the pressure ulcer's progression to healing. Another resident reported pain in his buttocks, and upon examination, open areas were found. The resident's care plan did not include pressure reduction interventions, and there was no pressure reduction cushion in his recliner. The facility's policy required weekly documentation of wounds, but there was no documentation of the size, number of open areas, or specific locations of the pressure ulcer. The facility failed to ensure that staff were aware of and implemented the necessary interventions for pressure ulcer prevention and care.
Inaccurate PBJ Data Submission for Nursing Coverage
Penalty
Summary
The provider failed to accurately submit Payroll Based Journal (PBJ) data for one federal fiscal quarter, specifically Quarter 4, 2024. The PBJ records submitted to the Centers for Medicare and Medicaid Services (CMS) indicated that there was no licensed nursing coverage for 24 hours on specific dates in September 2024. However, a review of the provider's employee timecards, staffing schedules, and residents' electronic medical records (EMR) showed that there was indeed licensed nursing coverage during those times. An interview with the administrator and nurse manager revealed that the nurse manager was responsible for creating the nursing schedule but did not participate in the PBJ submission process. The administrator, who submitted the records, relied on an electronic payroll system to automatically obtain information from individual staff timecards and manually entered agency staff hours. The administrator was unaware of the discrepancies in the PBJ reports and did not know how to access them. She speculated that the errors might have been due to manual entry of agency staff hours, but some missing coverage days were not staffed by agency staff, leaving the cause of the incorrect reporting unresolved.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to accurately identify and implement enhanced barrier precautions (EBP) for residents with care concerns requiring personal protective equipment (PPE). Observations revealed that there was no PPE available in the hallway or residents' rooms, and residents with wounds or indwelling medical devices were not placed on EBP. For instance, a resident with a wound on her right lower extremity was observed without any PPE or EBP signage in her room, despite having a dressing order for her wound. Interviews with staff indicated a lack of understanding and implementation of EBP protocols, with some staff unaware of the criteria for placing residents on EBP. The facility also failed to utilize appropriate hand hygiene and gloves during resident care. A certified nursing assistant (CNA) was observed performing various tasks, such as removing hair rollers, taking vital signs, and assisting with showers, without proper hand hygiene or glove changes. Shared resident care items, such as razors and lotions, were not disinfected between uses, and expired products were found in multiple areas, including the beauty shop and hopper rooms. Staff interviews revealed a lack of training and awareness regarding the cleaning and disinfection of shared items and the importance of hand hygiene. Additionally, the facility did not appropriately maintain and dispose of resident care items in hopper rooms, the shower room, and the beauty shop. Observations showed expired products, improperly stored items, and a lack of alcohol-based hand sanitizers in these areas. Staff were observed disposing of trash without washing their hands, and there was no clear policy for checking and removing expired products. Interviews with the director of nursing and other staff members highlighted a lack of oversight and responsibility for ensuring proper infection control practices and maintaining a clean and safe environment for residents.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that resident care plans were updated to reflect the current needs of several residents, leading to deficiencies in care. Resident 34 experienced multiple falls, including one that resulted in a laceration requiring emergency room treatment. Despite being identified as at risk for falls, her care plan was not updated with new interventions following these incidents. Similarly, residents 4 and 9, who also experienced multiple falls, did not have their care plans updated with fall prevention interventions, despite the facility's policy requiring such updates. Resident 10, who had a history of urinary tract infections (UTIs), did not have her care plan updated to reflect ongoing issues with UTIs, despite multiple antibiotic treatments. The care plan had not been revised since March of the previous year, failing to address her recurrent infections. Additionally, resident 29, who attempted to leave the facility without staff knowledge, was identified as at risk for elopement, but her care plan did not reflect this risk or the interventions put in place following the incident. Residents 7 and 11 also had deficiencies in their care plans. Resident 7, who developed a facility-acquired pressure ulcer, did not have her care plan updated to include the use of pressure-reduction devices. Resident 11, who was prescribed psychotropic medications, did not have her care plan updated to monitor for adverse effects or include non-pharmacological interventions for her hallucinations and anxiety. These oversights indicate a systemic issue with the facility's care planning process, as care plans were not consistently updated to reflect residents' changing needs and conditions.
Inadequate Chemical Storage and Security
Penalty
Summary
The provider failed to ensure that chemicals were stored securely and in accordance with their written instructions, leading to potential accident hazards. Observations revealed that chemicals were stored under sinks in four different rooms, including the Garden Terrace hopper room, Happy Trails hopper room, beauty shop, and shower room. In each instance, the cabinets or rooms were not locked, and various chemicals, some with broken tops or outdated labels, were accessible. Signs were present indicating that chemicals should be kept in locked cupboards, but these instructions were not followed. Interviews with staff, including CNAs, housekeeping, and the DON, confirmed that there was an expectation for chemicals to be stored in locked areas and not under sinks. However, there was a lack of awareness and adherence to these expectations. The DON and nurse manager were unaware of the unlocked cabinets and the presence of chemicals under sinks, despite previous instructions that products should not be stored there. The facility's chemical safety policy emphasized the safe use and storage of chemicals, but it was primarily focused on dietary staff and food contamination, indicating a possible gap in comprehensive chemical storage practices across the facility.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving incorrect medication administration. Resident 33 was mistakenly given another resident's medications, including Tylenol, Olanzapine, Celecoxib, and Tamsulosin, by a certified medication aide. Similarly, Resident 34 received Carbidopa/Levodopa, a medication not ordered for them, leading to the involvement of poison control to monitor for adverse reactions. Resident 11, who was not diabetic, was mistakenly administered 7 units of NovoLog insulin after being confused with another resident. This error was documented, and the resident's primary doctor and daughter were notified. However, there were no further blood glucose checks recorded in the resident's electronic medical record, and the nurse manager was unsure if any education or review of the error had been completed. Resident 29 received Lorazepam, a medication that had been discontinued, due to a failure to verify the medication in the electronic medication administration record before administration. The medication was not removed from the narcotic drawer, leading to the error. The facility's medication error policy outlines steps to prevent, identify, report, and address such errors, but these were not effectively implemented in these cases.
Failure to Monitor and Document Resident's Nutritional Intake
Penalty
Summary
The provider failed to ensure adequate monitoring and documentation of a resident's nutritional intake, leading to consistent weight loss. During a lunch meal observation, Resident 24, who has severe cognitive impairment and requires assistance with eating, was not adequately encouraged or assisted to consume her meal. The resident consumed only a small portion of her meal, and no documentation of her consumption was made in the electronic medical record (EMR). Interviews with staff revealed a lack of awareness regarding the resident's meal consumption and weight loss, as well as issues with obtaining accurate weights and documenting meal intake. The resident's care plan included multiple focus areas related to nutrition and hydration, yet there was no update addressing her significant weight loss of over 10% in the past three months. The Registered Dietician Licensed Nutritionist noted the weight loss and suggested considering an appetite stimulant and encouraging meal intake. However, meal documentation was incomplete, with many meals lacking records of consumption, particularly evening meals. Additionally, there was no hydration documentation in the EMR, and a task to record supplemental fluids was only added after the observation date. This lack of documentation and monitoring contributed to the deficiency in maintaining the resident's health through adequate nutrition.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adequately implement and monitor an effective antibiotic stewardship program, as evidenced by multiple deficiencies in the management of urinary tract infections (UTIs) and antibiotic use. Resident 10, who had a history of chronic kidney disease, type two diabetes mellitus, and recurrent UTIs, was observed to have been prescribed antibiotics multiple times over several months without clear documentation or consistent use of decision-making tools like the SBAR form. The infection preventionist acknowledged the lack of documentation and the absence of a structured process for determining the necessity of urine dips or urinalysis, which contributed to the repeated antibiotic prescriptions. Interviews with staff, including the infection preventionist and registered nurses, revealed inconsistencies in the process of obtaining and documenting orders for urine dips and urinalysis. Staff were not consistently documenting the reasons for performing urine dips or obtaining urinalysis, and there was no standardized form in use to guide these decisions. The infection preventionist admitted that the facility's tracking of infections and antibiotic use was limited to a spreadsheet discussed at QAPI meetings, and there was no comprehensive system in place to ensure appropriate antibiotic use. The facility's infection control and prevention policy outlined the responsibilities of the infection preventionist, including tracking and reporting antibiotic use and infections. However, the policy was not effectively implemented, as evidenced by the lack of systemic data collection and documentation. The report highlighted that from August to December, multiple residents were prescribed antibiotics more than once, and there was no clear evidence of lab-confirmed infections for all cases. This deficiency in antibiotic stewardship could potentially lead to adverse events associated with antibiotic use, although the report did not explicitly state such consequences.
Failure to Secure and Account for Controlled Medication
Penalty
Summary
The deficiency involved the failure to secure and account for a controlled medication, specifically morphine sulfate, for a resident. On the morning of November 23, 2024, RN D counted the resident's narcotics at the start of her shift and found no discrepancies. However, at the end of her shift, RN D did not perform the required narcotic count with LPN R, who initially refused to conduct the count until RN D insisted. The following day, RN D was called back to the facility to assist in locating the missing morphine sulfate, which was not accounted for. LPN R had already left the facility without resolving the issue. Nurse manager C was informed of the missing six milliliters of morphine sulfate and worked with the pharmacy to investigate the incident. Initially, the missing medication was not considered theft until the pharmacy clarified it as such. The controlled drug receipt/record/disposition form indicated that the last dose of morphine sulfate was administered on November 16, 2024, with six milliliters remaining. The facility's undated Narcotic Count Policy required narcotics to be counted by licensed nursing personnel at the beginning and end of each shift, which was not adhered to in this instance.
Failure to Timely Report Missing Controlled Medication
Penalty
Summary
The provider failed to report the missing controlled medication, specifically six milliliters of morphine sulfate, to the South Dakota Department of Health (SD DOH) in a timely manner. The incident was initially discovered on November 24, 2024, but the Facility Reported Incident (FRI) was not submitted until December 4, 2024. Interviews with the nurse manager and the administrator revealed a lack of awareness regarding the timeline requirements for reporting such incidents to the SD DOH. The nurse manager admitted to not following the facility's policy for reporting potential diversion of controlled substances and only began the paperwork for drug diversion on November 25, 2024, after being informed by the pharmacy that it was a misappropriation of a personal item. The facility's policy on Reporting and Investigating Diversion of Controlled Substances requires that investigations be completed within 48 hours of discovering an incident, with the severity of the theft or loss evaluated for reporting purposes. However, both the nurse manager and the administrator acknowledged that they did not adhere to this policy. The administrator also confirmed the failure to follow the policy for reporting potential diversion of controlled substances. The report highlights the deficiency in timely reporting and adherence to established protocols for handling controlled substances within the facility.
Resident Elopement Due to Inactive Door Alarm
Penalty
Summary
The deficiency involved a resident identified at risk for elopement who managed to leave the facility without staff knowledge. The incident occurred when a certified nursing assistant (CNA) noticed that a fire exit door in the living room was slightly open, and the alarm did not sound. The resident was found standing on the sidewalk by the door, having last been seen eating lunch in the dining room. The resident stated she was going to get hot chocolate, indicating she had left the facility without staff awareness. The failure to ensure the door alarm was reactivated after being turned off led to the resident's elopement. The door alarm system was checked immediately after the incident and was found to be turned off. This oversight in reactivating the alarm system allowed the resident to exit the building unnoticed. The resident was wearing a Tile tracking device and a watch capable of tracking her location, but these measures did not prevent the elopement. The resident involved had a Brief Interview for Mental Status (BIMS) assessment score of 10, indicating moderate cognitive impairment. At the time of the incident, the resident was wearing tracking devices, and her vital signs were within normal limits with no injuries noted. The incident highlighted a lapse in the facility's safety protocols, specifically regarding the management and monitoring of door alarms, which are crucial for preventing elopement in residents at risk.
Failure to Report and Investigate Bruise of Unknown Origin
Penalty
Summary
The provider failed to report and investigate a bruise of unknown origin on a resident's forehead, which was observed on 8/06/24. The bruise was not reported to the nurse manager or the director of nursing (DON) for further investigation. Interviews revealed that the certified nursing assistant (CNA) and licensed practical nurse (LPN) involved did not know how or when the bruise occurred. The LPN had spoken to the resident's daughter, who was unaware of the bruise, and failed to document the conversation or notify the family and physician promptly. The LPN also did not report the bruise to the charge nurse or DON, nor did she document it on the medication administration record (MAR) for daily monitoring. The director of nursing (DON) and the administrator acknowledged that the bruise should have been investigated and reported according to the facility's bruise policy. The policy required that bruises be documented, monitored, and reported to the family and physician. However, the bruise was not documented in the resident's electronic medical record, and the family was not notified. The administrator admitted that the process for reporting bruises was broken and had not been monitored recently, leading to a lapse in following the established procedures.
Dishwasher Maintenance Deficiency
Penalty
Summary
The provider failed to ensure that the dishwasher in the kitchen was adequately cleaned and delimed on a regular basis, leading to a buildup of food scum and limescale. During an initial kitchen observation, surveyors noted that the dishwasher, which was in use for cleaning breakfast dishes, had a line of limescale buildup on the outside of the door, food scum on the outside borders and inside seams of the doors, and limescale on the wash arms and piping inside the machine. Interviews with kitchen staff revealed a lack of knowledge regarding the cleaning schedule, with dietary aide J having never cleaned or delimed the dishwasher and cook I not having been tasked with this responsibility for a long time. The night shift was identified as responsible for these tasks, but there was no evidence of regular completion. Further investigation revealed that the administrator believed the dishwasher was supposed to be delimed weekly, with instructions and a deliming schedule posted on the wall. However, the last recorded deliming was approximately two months prior. The facility's dishwashing policy emphasized the importance of cleaning and sanitizing food preparation equipment to prevent disease, with the dietary manager responsible for monitoring task completion and record accuracy. The failure to adhere to this policy and maintain the dishwasher's cleanliness contributed to the observed deficiency.
Failure to Report Abnormal Blood Sugars and Improper Medication Storage
Penalty
Summary
The provider failed to report abnormal blood sugar levels for a resident as per the physician's orders. The resident had a doctor's order to check blood sugar four times daily and report if levels were below 60 or above 500. On two occasions, the resident's blood sugar levels were recorded as 542 and 517, but there was no documentation that the doctor was notified. Interviews with staff, including an LPN and a nurse manager, confirmed that the high blood sugars were not reported, despite a new policy in place to ensure such parameters are monitored and reported. The administrator was unaware of the failure to report these abnormal results. Additionally, the provider did not adhere to their policy regarding the storage of prescription medications. A resident had a prescription ointment on her bedside table without a physician's order for bedside storage. The resident, who had severe cognitive impairment, was unable to use the ointment independently. Interviews with staff, including an LPN and the DON, revealed that the ointment was intended for staff use during care and should have been stored in the medication room. The facility's policy requires a written order and assessment for bedside medication storage, which was not followed in this case.
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 service, which had the potential to affect all residents receiving the main menu in the facility. The menu for lunch on the specified date included one cup of taco bake and a 2/3 cup portion for the pureed version. However, during the observation of the lunch service, it was noted that Cook H used a 1/2 cup scoop for both the regular and pureed taco bake, resulting in serving sizes that were 50% and 33.33% less than the menu requirements, respectively. Interviews with the kitchen staff revealed that Cook H, who had been working at the facility for about three weeks, was not aware of the correct serving sizes and had been trained to use a 1/2 cup scoop for every recipe. Neither Cook H nor Cook I were aware of the correct portion sizes as listed on the posted menu. The acting dietary manager, Administrator A, was also unaware of the incorrect portion sizes being served, as she had recently taken over the role following the departure of the previous dietary manager.
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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