Good Samaritan Society De Smet
Inspection history, citations, penalties and survey trends for this long-term care facility in De Smet, South Dakota.
- Location
- 411 Calumet Avenue Nw, De Smet, South Dakota 57231
- CMS Provider Number
- 435074
- Inspections on file
- 19
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Good Samaritan Society De Smet during CMS and state inspections, most recent first.
Two residents who required significant staff assistance experienced unmet care needs due to insufficient overnight staffing. One developed a Stage II pressure ulcer after admission, with incomplete care planning and inadequate repositioning, while another was left incontinent overnight after a CNA failed to provide timely toileting assistance. Staff interviews and records confirmed that only one CNA and one nurse were often responsible for up to 40 residents overnight, making it difficult to meet care needs, especially for those with high acuity.
A resident admitted after orthopedic surgery, who was bedbound and at risk for pressure ulcers, did not have a completed care plan or documented preventive interventions. Staff failed to consistently reposition the resident or document skin care, resulting in the development of a Stage II pressure ulcer and moisture-related skin damage, despite facility protocols requiring such preventive measures.
A resident with multiple complex medical conditions was admitted without a baseline care plan being completed within 48 hours, despite clear risks for pressure ulcers and specific care needs. The care plan lacked essential information about the resident's medical devices, mobility status, and required interventions. Staff responsible for care planning were unavailable and no other nurses were trained to complete the baseline care plan, resulting in reliance on verbal communication and a lack of awareness about the development of a pressure ulcer.
A resident in a LTC facility experienced neglect when staff failed to follow physician orders after a fracture. The resident was not taken to the ER immediately after a fall, and post-discharge care instructions for a leg immobilizer and elevation were not consistently followed. Despite the resident's intact cognition, her attempts to communicate care needs were dismissed, leading to improper care of her fracture.
A resident at risk for pressure ulcers developed a pressure ulcer on her left heel due to inadequate preventative interventions. Despite having heel protectors and an air mattress, the facility failed to conduct a significant change assessment upon the resident's return from the hospital and did not reassess her pressure ulcer risk. Skin assessments were not properly conducted, with documentation inconsistencies noted.
A resident fell from a mechanical lift during a transfer, resulting in a leg fracture. The incident was not reported to the DON until the following day, delaying the investigation and reporting to the SD DOH. The facility's policy requires immediate reporting of such incidents, but inconsistent accounts from the CNA and a lack of timely notification led to a breach in protocol.
Failure to Provide Adequate Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient caregiver staff were available to meet the needs of residents who required assistance with repositioning, toileting, and incontinence care. One resident, who was dependent on staff for repositioning due to a full-length leg cast and other medical conditions, developed a Stage II pressure ulcer to her coccyx after admission. Documentation and interviews revealed that her care plan was incomplete, lacking specific interventions for her high risk of pressure ulcers, and that staff were not always able to provide the necessary repositioning and skin care. The resident's Braden Scale score indicated she was at risk, and her skin was already compromised on admission, but the care plan did not address her cast, wound vac, catheter, or specific assistance needs. Another resident, who relied on staff for toileting and incontinence care, reported that a CNA turned off her call light without providing assistance, resulting in an episode of incontinence and the resident remaining in wet garments overnight. The resident and her daughter both described multiple instances where timely assistance was not provided, and the daughter noted an increase in wet clothing over the past month. The facility did not have the capability to audit call light response times, and staffing records showed that on several overnight shifts, only one CNA and one nurse were available to care for up to 40 residents. Staff interviews confirmed that overnight staffing was often limited to one CNA and one nurse, with the CNA responsible for all resident rounds and call lights. Staff described difficulty meeting resident needs during these shifts, especially when caring for residents with high acuity or end-of-life needs. The facility's resource packet and facility assessment did not document current staffing levels or provide clear guidance on how to ensure adequate staffing to meet resident acuity and needs. These actions and inactions led to unmet care needs, including the development of a preventable pressure ulcer and unaddressed incontinence episodes.
Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A resident was admitted to the facility following surgery to place a rod in her left leg and was dependent on staff for repositioning and pain management. Upon admission, the resident had a full-length cast, was non-weight-bearing, and required moderate to maximum assistance for movement. The initial skin assessment documented a large, red, flaky, and macerated area on her buttocks, but no open wounds. The resident's Braden Scale score indicated she was at risk for developing pressure ulcers, and she was placed on an air mattress. However, the care plan was not completed to address her specific needs, including her cast, wound vac, urinary catheter, transfer status, risk for pressure ulcers, or interventions for prevention. Documentation and interviews revealed that the resident remained in bed for several days, experienced significant pain, and was only repositioned as tolerated. Staff noted that she sometimes refused repositioning due to discomfort, and there was inconsistent documentation of repositioning tasks. Nursing staff and CNAs were unclear about the frequency and extent of repositioning provided, and there was a lack of clear communication and documentation regarding her care. The wound nurse and DON were not present during the resident's stay, and no baseline care plan or wound data collection form was completed. The expectation was that interventions such as frequent repositioning and skin care would be implemented, but these were not documented or consistently carried out. The resident developed a Stage II pressure ulcer to her coccyx and associated moisture-related skin damage to her perineum, which was not present upon admission. The physician confirmed that these skin injuries were preventable and not present when the resident was discharged from the hospital prior to admission to the facility. The facility's own wound care protocols required comprehensive management and documentation for residents at risk, but these were not followed. The lack of a completed care plan, failure to implement and document preventive interventions, and insufficient staff communication contributed to the resident developing a pressure ulcer during her stay.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a baseline care plan within 48 hours of admission for a newly admitted resident who subsequently developed a Stage II pressure ulcer. The resident, who had an intact mental status and multiple complex medical conditions including infection due to a knee prosthesis, Type II Diabetes Mellitus, and Chronic Kidney Disease Stage 3, was admitted with specific physician orders such as a diabetic diet, non-weight-bearing status, wound vac, and intravenous antibiotics. Assessments documented that the resident was at risk for pressure ulcers, required moderate to maximum assistance for mobility, and had significant skin issues upon admission, including redness and maceration on the buttocks. Despite these findings, the resident's care plan did not reflect critical information such as the presence of a full-length leg cast, wound vac, urinary catheter, intravenous antibiotics, transfer and weight-bearing status, level of assistance needed for activities of daily living, risk for pressure injuries, pain management, or necessary interventions to prevent pressure ulcers. There was no documentation that a baseline care plan was completed within the required 48-hour timeframe after admission. Interviews with facility staff revealed that the DON, who was responsible for completing baseline care plans, was not present during the resident's initial days in the facility and no other nurses were trained to complete this task. As a result, staff relied on verbal reports to communicate care needs, and the administrator and DON were unaware that the resident had developed a pressure ulcer during her stay. The facility's policy required a baseline care plan to be developed upon admission and provided to the resident and their representative, but this was not followed in this case.
Neglect in Following Post-Fracture Care Orders
Penalty
Summary
The facility failed to protect a resident from neglect by not following physician orders after the resident sustained a left lower extremity fracture. The incident began when the resident was being transferred using a sit-to-stand lift and was lowered to the floor by a CNA. Following the incident, the resident complained of left leg pain, and orders for an x-ray and doppler were received from her primary care provider. However, these tests were not scheduled until two days later, and the resident was not taken to the emergency room until the x-ray results confirmed a fracture. Upon discharge from the hospital, the resident was given specific orders to wear a leg immobilizer, remain non-weight bearing, and keep her leg elevated. Despite these instructions, the resident's daughter observed that the immobilizer was not always used correctly, and the resident's leg was not consistently elevated. The daughter reported that the CNAs dismissed the resident's attempts to communicate the proper care instructions, and there were instances where the immobilizer was left off when the resident was in bed. The resident's medical history included a fracture of the tibia, urinary tract infection, type 2 diabetes, macular degeneration, chronic kidney disease, arthritis, hearing loss, and folate deficiency. Despite having an intact cognitive status, the resident experienced increased confusion, which was later attributed to a urinary tract infection and pain. The facility's failure to adhere to the prescribed care plan and the resident's reports of improper care contributed to the neglect of the resident's needs, as outlined in the facility's policies on abuse and neglect.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The provider failed to initiate preventative interventions for a resident who was at risk for and developed a pressure ulcer on her left heel after fracturing her left lower leg during a fall. The resident was observed with heel protector boots and an air mattress, but the preventative measures were not adequately implemented. The resident's care plan included interventions for pressure ulcer prevention, such as providing a pressure relief cushion and an air mattress, but these were not effectively utilized to prevent the development of a pressure ulcer. The resident's medical record indicated she was at mild risk for developing a pressure ulcer, with a Braden Scale score of 15. Despite this, a significant change assessment was not completed when she returned from the hospital, and she was not reassessed for a potential change in pressure ulcer risk. Preventative measures in place prior to the development of the pressure ulcer included a daily multivitamin with zinc and nutritional supplements, but these were insufficient to prevent the ulcer. Interviews with staff revealed that the skin assessments were not conducted as required, with documentation being copied and pasted rather than accurately reflecting the resident's condition. The wound nurse documented the pressure ulcer as a suspected deep tissue injury, but the documentation was inconsistent, and the wound was later noted as healed without proper assessment. The facility's policy required systematic assessment and documentation of residents' skin conditions, but these procedures were not followed, leading to the deficiency.
Delayed Reporting of Resident Fall Incident
Penalty
Summary
The provider failed to report an incident involving a resident who fell from a mechanical lift during a transfer in a timely manner to the South Dakota Department of Health (SD DOH). On October 21, 2024, the resident was being transferred using a sit-to-stand lift when she was lowered to the floor by a CNA due to improper positioning and lack of readiness of the wheelchair. The resident complained of left leg pain later that day, and subsequent medical evaluations revealed a fracture in her left lower leg, necessitating emergency orthopedic care. The incident was not reported to the director of nursing until the following day, October 22, 2024, which delayed the investigation and reporting to the SD DOH. The facility's policy mandates immediate reporting of any suspected abuse, neglect, or injuries of unknown origin to the administrator or designated authority. However, the registered nurse involved did not notify the director of nursing on the day of the incident, leading to a breach in protocol. The delay was further compounded by inconsistent accounts from the CNA involved, which did not align with the resident's report, causing a one-day delay in initiating the investigation and reporting the incident.
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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