Lake Andes Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Andes, South Dakota.
- Location
- 740 East Lake St, Lake Andes, South Dakota 57356
- CMS Provider Number
- 435097
- Inspections on file
- 15
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lake Andes Senior Living during CMS and state inspections, most recent first.
Kitchen equipment surfaces and food storage areas were found to be unclean, with buildup of dirt and unidentified substances on the dishwasher and freezer, and improper storage of food items. Staff interviews and cleaning schedules revealed that required cleaning tasks were not consistently completed or documented, contrary to facility policy.
A resident with Alzheimer's dementia and severely impaired cognition, who continued to smoke, did not receive a required quarterly smoking evaluation as outlined in the facility's policy. The care plan specified regular assessments to determine the need for supervision during smoking, but a quarterly evaluation was missed, as confirmed by the ADON.
A resident's oxygen tubing was repeatedly observed on the floor and not replaced, contrary to facility infection control protocols. Staff interviews confirmed that tubing should be stored on the machine and replaced if contaminated, but these practices were not consistently followed.
A resident at risk for elopement exited a facility unsupervised despite wearing a Wanderguard, which alarmed correctly. Staff were occupied with other residents, and the resident was found across the street by a CNA. The resident had a history of exit-seeking behavior, and staffing levels were noted as insufficient. Elopement drills were not regularly conducted, and there was no documentation of such drills.
The facility failed to ensure proper diabetic care for several residents, with inconsistent monitoring and documentation of blood sugar levels and lack of physician notification. Residents experienced both high and low blood sugar levels without appropriate interventions or documentation, highlighting a deficiency in care standards.
The facility failed to manage COVID-19 cases effectively, leading to improper precautions and further transmission among residents. Observations showed that residents were not isolated properly, and staff did not follow proper PPE protocols, such as hand hygiene and mask changes. Additionally, Enhanced Barrier Precautions were not implemented correctly for residents with urinary catheters and wounds, as staff did not consistently use gowns, gloves, or eye protection.
The facility failed to maintain a clean and homelike environment for its 39 residents, with observations of rusted and stained air conditioning units, water-stained ceiling tiles, and dust accumulation on air return grates. Peeling paint and exposed wood on doors and door frames created uncleanable surfaces, while bathroom facilities showed signs of neglect. Cluttered storage areas and uncleanable surfaces in common areas further contributed to the deficiency.
The facility did not have a registered nurse (RN) scheduled for eight consecutive hours on two weekends in May 2023. The executive director was aware of the issue and confirmed that while a nurse was always present, it was not always an RN. Staff schedules and payroll records confirmed the lack of RN coverage on specific dates.
The provider failed to ensure proper labeling and storage of food items for resident consumption. Observations showed that several freezers and a resident refrigerator contained unlabeled and undated food items, some stored for extended periods. The dining services manager confirmed these issues, citing problems with labels smudging or falling off. The provider's policies on food storage and labeling were not followed, leading to this deficiency.
The facility failed to ensure resident safety and well-being due to inadequate infection control and diabetic care. Staff did not follow COVID-19 precautions, and the environment was not maintained as safe and homelike. The diabetic care program did not address hypoglycemic and hyperglycemic risks, and physician notifications were not made according to orders. Additionally, the facility lacked an effective QAPI program.
The facility's QAPI program was ineffective, with deficiencies in infection control and diabetic care. During a COVID-19 outbreak, infected residents shared rooms with uninfected ones, violating policy. The executive director was unaware of issues in diabetic care, including lack of physician notification and missing documentation. The QAPI policy required staff involvement and training, which was not effectively implemented.
The facility did not provide mandatory Quality Assurance and Performance Improvement (QAPI) training to seven staff members, as revealed by a review of their files, which lacked documentation of such education.
The facility failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags. One resident was observed with an uncovered bag under his wheelchair in common areas, while another had an uncovered bag visible from the hallway. The DON confirmed that staff were educated on covering bags, and dignity covers were available, but the Catheter Care Policy did not address this requirement.
The facility failed to provide timely and accurate Medicare notices to three residents before their discharge from Medicare Part A skilled services. One resident did not receive a SNF ABN, and the NOMNC provided had incorrect information. Another resident's NOMNC was unsigned and contained incorrect details, while the third resident received notices without the required two-day notice period. The forms also lacked the provider's address and phone number.
The facility failed to maintain privacy for residents sharing adjoining rooms with a shared bathroom. Bathroom doors were replaced with shower curtains, which did not provide adequate privacy, leading to discomfort and fear among residents. The shared bathrooms were also used for storage or as conference rooms, further compromising privacy. The facility's policy on resident dignity was not followed, and there was no policy regarding the use of shower curtains.
The facility failed to update care plans for two residents, leading to deficiencies in addressing fall, elopement, and infection control risks. One resident's care plan lacked documentation for fall and elopement interventions, while another's did not include enhanced barrier precautions despite having open wounds and a catheter. Staff did not follow necessary protocols, and protective equipment was absent.
The facility failed to update care plans for two residents with specific medical needs. One resident with a central venous catheter for dialysis had an outdated care plan referencing a fistula, while another resident managing her diabetes independently had no care plan reflecting her self-care activities. The facility's care planning policy was outdated and lacked proper identification.
The facility failed to maintain accurate documentation in resident records, with errors in physician notification for abnormal blood sugar levels and incorrect resident information in EMRs. Interviews revealed a lack of written policies on diabetic care and inconsistencies in documentation practices.
A resident with severe cognitive impairment did not have proper documentation of a power of attorney for healthcare, leading to unauthorized release of medical information to a friend. The friend, listed as an emergency contact, gave verbal consent for treatments and was informed about medication changes without formal authorization. Staff interviews revealed a lack of awareness about the need for proper documentation, potentially violating HIPAA regulations.
A resident experienced a significant weight loss without being re-weighed as required by facility policy, and another resident was self-administering insulin without a completed safety assessment or physician's order. The facility's policies for weight monitoring and medication self-administration were not followed, leading to these deficiencies.
A resident's PRN lorazepam order was not renewed beyond 14 days, leading to a lapse in their medication regimen. The facility's staff, including the regional nurse consultant and nursing directors, were unaware of the oversight until it was brought to their attention. The facility's policy requires PRN psychotropic medications to be limited to 14 days unless renewed after a prescriber's examination.
Failure to Maintain Sanitary Kitchen and Food Storage Conditions
Penalty
Summary
Surveyors observed that kitchen equipment surfaces and food storage areas were not maintained in a clean and sanitary condition. The top of the dishwasher had a buildup of an unidentified substance, such as dirt, dust, or dried cleaning chemicals, which remained uncleaned over several days. The freezer contained dirt particles and spilled material on the bottom, and single-serving ice cream cups were stored on the same shelf as frozen bacon. There was also dirt buildup around appliances and preparation tables, with evidence that tables and appliances had not been moved to clean underneath them. These unsanitary conditions were confirmed through multiple observations on different days. Interviews with dietary staff revealed that cleaning responsibilities were shared among all kitchen staff and that a cleaning schedule was in place, requiring daily sign-off. However, the cleaning schedule showed multiple instances where staff had not signed off on their cleaning duties, both during the week of the survey and in the previous four weeks. The dietary services manager acknowledged that some cleaning tasks were not being completed or documented as required. Review of the facility's policy confirmed that food was to be stored in clean, dry, and contaminant-free areas, which was not consistently followed.
Missed Quarterly Smoking Evaluation for Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that smoking evaluations were completed quarterly for a resident who continued to smoke. The resident, who had a primary diagnosis of Alzheimer's dementia and a severely impaired cognition as indicated by a BIMS score of 7, was identified as being at risk for injury related to smoking. The care plan for this resident included interventions such as completing smoking evaluations on admission, quarterly, and as needed to determine the resident's ability to smoke independently or require staff assistance. However, record review showed that a quarterly smoking evaluation was missed, as there was a gap between completed assessments. Interview with the assistant director of nursing (ADON) confirmed that the resident, despite having gone six months without smoking, should have still been considered a smoker and required ongoing evaluations per facility policy. The facility's updated smoking policy required all residents who smoke to be assessed during each quarterly or comprehensive MDS assessment, and further evaluated for safe smoking practices. The ADON acknowledged that a quarterly smoking evaluation had been missed for this resident, which was not in compliance with the facility's policy.
Failure to Follow Infection Control Practices for Oxygen Tubing
Penalty
Summary
A deficiency was identified when a resident's oxygen tubing, specifically the nasal cannula that contacts the resident's face, was repeatedly observed lying on the floor while not in use. On multiple occasions, the tubing remained on the floor even after the resident had left the room, and it was not replaced despite being contaminated. The resident confirmed that staff sometimes rolled up the tubing and placed it on the machine, but at other times allowed it to remain on the floor, and that the tubing was not replaced when this occurred. Interviews with staff, including the ADON and CNAs, revealed that facility protocol requires oxygen tubing to be rolled up and stored on the machine when not in use, and that tubing found on the floor should be replaced. However, observations and resident statements indicated that these infection control practices were not consistently followed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident from eloping, despite the resident being identified as at risk for elopement. On the evening of the incident, the resident, who was wearing a Wanderguard, exited the facility through the front door without supervision. Although the Wanderguard alarm functioned correctly, all staff members were occupied with other residents at the time, and the resident was able to leave the premises. The resident was later found across the street by a CNA and returned to the facility without injury. Interviews with staff revealed that the resident frequently attempted to exit the building and had previously been able to leave the facility without the Wanderguard alarming. The facility's staff, including CNAs and the LPN on duty, confirmed that the resident had a history of exit-seeking behavior and had previously exited the building. The LPN noted that staffing levels during the evening shift were insufficient, which may have contributed to the inability to prevent the elopement. Additionally, the facility's regional nurse consultant and DON acknowledged that elopement drills were not regularly conducted, particularly on the night shift, and there was no documentation available for such drills. The resident's care plan and medical records indicated a known risk for elopement, with multiple documented attempts to exit the facility.
Deficiency in Diabetic Care and Physician Notification
Penalty
Summary
The provider failed to ensure proper care and services for diabetic residents, specifically in monitoring blood sugar levels and notifying physicians when levels were outside the normal range. This deficiency affected four out of seven diabetic residents, leading to instances where blood sugar levels were not managed according to accepted clinical standards. Interviews and record reviews revealed that interventions and timely follow-ups were inconsistently documented, contributing to the deficiency. Resident 38, who has type 1 diabetes mellitus and other health conditions, experienced fluctuating blood sugar levels. On multiple occasions, her blood sugar dropped to dangerously low levels, yet there was no documentation of interventions or physician notifications. Similarly, resident 22, with type 2 diabetes and other serious health issues, had several high blood sugar readings without any record of physician notification. Resident 3, also with type 2 diabetes, had high blood sugar levels recorded without any documented physician contact. Resident 20, who is severely cognitively impaired, had high blood sugar levels without physician notification as well. The facility lacked a written policy on hypoglycemia management or diabetic care, relying instead on standing orders that were not reviewed by the current DON. Interviews with staff, including the ADON, revealed inconsistencies in the process for managing low or high blood sugar levels, with some staff unsure of the facility's policy. The deficiency was further highlighted by the lack of documentation of physician notifications for numerous blood sugar readings outside the normal range.
Removal Plan
- Diabetic residents #3, #20, #22, and #38 who receive insulin will be managed with the glycemic management protocol given by the medical directors' guidelines.
- Nurses (RN and LPN) as well as medication aides have been educated on hypoglycemia and hyperglycemia protocols.
- Nurses are to contact each individual residents' provider in event of a low or high blood sugar reading.
- Nurses were educated to document interventions for low or high blood sugar within the resident's EMR.
- Nurses have been educated on the importance of following each individual resident's guidelines given by the resident's medical provider to properly manage diabetes.
- Nursing staff education was completed by the DON and ADON to ensure those who are currently working are providing appropriate glycemic care and the steps to follow in the event of a low or high blood sugar reading.
- Glycemic management protocol instructs that the nurse on duty will contact the residents' provider during clinical hours or their hospital on-call provider after business hours.
- All nurses and medication aides not on shift will be educated prior to them coming on shift.
- All nurses and medications aides were educated on glycemic management protocols.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Inadequate COVID-19 Management and Infection Control
Penalty
Summary
The facility failed to manage COVID-19 cases effectively among 12 sampled residents, leading to improper precautions and further transmission of the disease. Observations revealed that residents who tested positive for COVID-19 were not isolated properly, with some negative residents remaining in the same room as their positive roommates. Staff were observed not following proper protocols for personal protective equipment (PPE) usage, such as not performing hand hygiene before and after glove use, and not changing N95 masks between rooms. Additionally, there were instances where staff did not wear PPE correctly, such as not securing N95 masks properly or wearing gowns outside of isolation rooms. The facility's records showed a lack of documentation regarding informing residents or their responsible parties about the risks of staying in the same room with COVID-19-positive roommates. Interviews with the Director of Nursing (DON) indicated that while there was an expectation to inform residents and document such communications, this was not consistently done. The facility's COVID-19 outbreak policy required placing residents with confirmed infections in single-person rooms when possible, but this was not adhered to, as evidenced by multiple residents remaining in shared rooms despite positive test results. Further deficiencies were noted in the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and wounds. Observations showed that staff did not consistently use gowns, gloves, or eye protection when providing care to these residents, contrary to the facility's policy. Interviews with staff revealed a lack of awareness and adherence to EBP protocols, with some staff unable to locate necessary PPE or unaware of the requirements for its use. This lack of compliance with infection control measures contributed to the facility's failure to prevent the spread of infections effectively.
Removal Plan
- All COVID-positive residents were moved in with other COVID-positive residents. All negative residents are grouped with well residents with no signs or symptoms of COVID. Other negative residents with known exposure, including resident #6, #38, and resident #8, are in the presumptive area with other presumptive residents.
- Staff have been educated on the importance of keeping all positive residents on isolation for 10 days. Staff are to redirect if they want to come out of their room.
- Staff education was completed by the DON and RN Nurse Specialist to ensure all staff who are currently working and are providing care to positive and presumptive residents knew how to properly DONN and DOFF PPE. PPE is put on prior to entering positive and presumptive rooms. This includes removing the gloves and gown inside the room and performing hand hygiene. The removal of the eye protection and mask happens outside the room. Masks and eye protection are discarded. Hand hygiene is performed again. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on properly wearing an N95 mask. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on proper hand hygiene after DOFFING PPE prior to assisting another resident. All those not on shift will be educated prior to them coming on shift.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for all 39 residents, as evidenced by multiple observations of uncleanable and deteriorating surfaces throughout the facility. Specific issues included rusted and stained air conditioning units, water-stained ceiling tiles, and dust accumulation on air return grates in several rooms. Additionally, there were numerous instances of peeling paint and exposed wood on doors and door frames, creating uncleanable surfaces. The bathroom facilities also showed signs of neglect, with missing caulking, peeling paint, and rusted fixtures. Further observations revealed cluttered storage areas with improperly stored items such as incontinent undergarments and hygiene wipes. The dining room and hallways had stained ceiling tiles and rusted vents, while the bathroom outside the director of nursing's office contained several uncleanable surfaces, including a cracked paper towel dispenser and a rusted menstrual products machine. The facility's executive director and director of nursing did not provide any disagreement or comment during the exit conference with the survey team.
Failure to Ensure RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for eight consecutive hours on two weekends in May 2023. An interview with the executive director revealed that he was responsible for filing the payroll-based journal (PBJ) reports and had been aware of the lack of RN coverage on specific dates. The executive director acknowledged that while there was always a nurse present in the building, it was not always an RN on weekends. A review of the staff schedule and payroll records confirmed the absence of RN coverage on Sunday, May 7, 2023, Saturday, May 27, 2023, and Sunday, May 28, 2023.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The provider failed to ensure that food items for resident consumption were appropriately labeled and stored in a safe and sanitary manner. Observations revealed that three out of five freezers contained food items that were not labeled or dated, including bags of fruit, waffles, French toast, frozen omelets, garlic bread, and frozen vegetables. Additionally, a resident refrigerator in the therapy room contained food items that were not labeled, dated, or discarded by the use-by date, such as fruit, yogurt, coffee creamer, and breaded meat. These items had been stored for extended periods, ranging from 11 to 28 days, without proper labeling or disposal. An interview with the dining services manager confirmed the presence of unlabeled food items in the freezers and resident refrigerator. The manager acknowledged that food items should have been labeled with a date received and an opened date, but noted issues with labels smudging or falling off. The provider's undated Food Storage Policy and the November 16, 2018, Outside Food and Food Storage policy outlined requirements for labeling and discarding food, which were not adhered to. The policies specified that leftover food must be used within seven days or discarded, and foods brought in from outside should be labeled with the resident's name, room number, and date, and discarded after 48 hours.
Deficiencies in Infection Control and Diabetic Care
Penalty
Summary
The facility failed to ensure the safety and well-being of its 39 residents due to inadequate administration by the Executive Director (ED) and Director of Nursing (DON). Key deficiencies included the lack of an effective infection control program, particularly in managing COVID-19 infections. Staff did not follow appropriate precautions, such as enhanced barrier precautions, proper use of personal protective equipment, and hand hygiene. Additionally, the facility did not maintain a safe, clean, and homelike environment, and failed to ensure personal privacy for residents sharing bathrooms. The facility also did not have a registered nurse on duty for at least eight consecutive hours on specified dates. The facility's diabetic care program was insufficient, as it did not address hypoglycemic and hyperglycemic risks for insulin-dependent residents. There were failures in notifying physicians according to blood glucose parameters and documenting interventions in residents' medical records. Interviews with the ED and Chief Operating Officer confirmed these deficiencies. Furthermore, the facility lacked an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the widespread system breakdown in ensuring resident safety and care.
Deficiencies in QAPI and Infection Control Programs
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by several deficiencies. The executive director (ED) acknowledged that while the QAPI committee met monthly with the medical director, there were significant lapses in the infection prevention and control program. During a COVID-19 outbreak, residents with confirmed infections were allowed to share rooms with uninfected residents, contrary to the facility's outbreak policy. The ED admitted this was a mistake and that the policy was not followed. Additionally, the ED was unaware of issues in the diabetic care program, specifically the lack of physician notification according to blood glucose parameters and missing documentation of interventions in the residents' electronic medical records. The facility's QAPI policy outlined a systematic approach to improving quality of life and care, involving all employees in ongoing efforts. However, the ED and Director of Nursing, who were responsible for the program, failed to develop a culture that involved input from staff, residents, families, and care partners. The policy also required leadership and facility-wide training on QAPI, ensuring staff had the necessary time, equipment, and training, which was not effectively implemented. These deficiencies were noted in the context of the facility's broader mission to provide a homelike environment and quality care to residents.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that seven employees, identified as B, C, J, P, Q, X, and Y, received mandatory education on the Quality Assurance and Performance Improvement (QAPI) process. This deficiency was identified through a review of the employees' files, which revealed a lack of documentation indicating that these staff members had been educated on the QAPI process as required by regulation during an extended survey.
Failure to Cover Urinary Catheter Drainage Bags
Penalty
Summary
The provider failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags. Resident 34 was observed on two occasions with an uncovered urinary catheter drainage bag hanging under his wheelchair, once in the dining room and once in the living room. The bag contained visible urine, which compromised the resident's dignity. Similarly, Resident 19 was observed in bed with an uncovered urinary catheter drainage bag hanging from the bed bar, visible from the hallway and half-filled with urine. The Director of Nursing (DON) acknowledged that urinary catheter drainage bags should have been covered and stated that staff had been educated on this matter. Dignity covers were available for all catheters, yet the facility's Catheter Care Policy did not address the need to cover urinary catheter drainage bags. The facility's Promoting/Maintaining Resident Dignity policy emphasized treating residents with respect and dignity, involving all staff in promoting and maintaining resident dignity and rights.
Failure to Provide Timely and Accurate Medicare Notices
Penalty
Summary
The provider failed to ensure that proper Medicare notices were completed and provided in a timely manner for three residents prior to their discharge from Medicare Part A skilled services. Resident 39 did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), and the Notice of Medicare Non-Coverage (NOMNC) provided had incorrect information, including an incorrect end date for coverage. Additionally, the NOMNC form lacked the provider's address and phone number, which are required details. Resident 12 also did not receive a SNF ABN, and the NOMNC provided was unsigned and contained incorrect information, such as an incorrect end date for coverage. The form also lacked the provider's address and phone number. Despite attempts to contact the resident's family, there was no evidence that the NOMNC was properly delivered or acknowledged. Resident 12 was moderately cognitively impaired, which may have impacted the communication process. Resident 38 received both the SNF ABN and NOMNC, but the notices were not provided at least two days before the end of skilled services as required. The forms also lacked the provider's address and phone number. The business office manager responsible for issuing these notices was on leave, and there was no policy in place regarding the required Medicare notices, contributing to the deficiencies observed.
Privacy Breach in Shared Bathrooms
Penalty
Summary
The facility failed to maintain privacy for four residents who shared adjoining rooms with a shared bathroom. Observations revealed that the bathroom doors had been removed and replaced with shower curtains, which did not provide adequate privacy. In one instance, a resident was unable to close the door because there was no door to close, and in another, a resident opened the curtain while seated on the toilet and interacted with surveyors. Conversations between staff and residents could be heard through the curtains, indicating a lack of privacy. Additionally, the shared bathrooms were used for storage or as conference rooms, further compromising resident privacy. Residents expressed discomfort and fear of being walked in on while using the bathroom. The director of nursing confirmed that the curtains did not provide privacy and needed to be changed, while the executive director acknowledged the inadequacy of the curtains and the expense of replacing bathroom doors. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by incidents where a resident entered another's room through the shared bathroom, causing distress. The facility lacked a policy regarding the use of shower curtains or shared bathrooms, and the retractable doors had not been replaced since they broke. The facility's handbook stated residents have the right to privacy, which was not upheld in these instances.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The provider failed to ensure that the care plans for two residents reflected their current needs, leading to deficiencies in care. Resident 139's care plan did not include necessary interventions for fall and elopement risks, despite being identified as a fall and elopement risk. Observations revealed that a fall mat was used, and a Wanderguard was ordered, but these interventions were not documented in the care plan. This lack of documentation indicates a failure to update the care plan to reflect the resident's current risk status and necessary interventions. Similarly, Resident 19's care plan did not include enhanced barrier precautions (EBP) despite having open wounds and an indwelling urinary catheter. Observations showed that staff did not use gowns or gloves when providing care, and there was no signage indicating the need for EBP. Interviews with staff confirmed that they were not following EBP protocols, and the director of nursing acknowledged the absence of necessary protective equipment and signage. This oversight in updating the care plan and ensuring staff compliance with EBP protocols contributed to the deficiency.
Failure to Update Care Plans for Residents with Specific Medical Needs
Penalty
Summary
The provider failed to ensure care plans were revised to reflect the current care needs of two residents. Resident 22, who had a central venous catheter (CVC) for dialysis treatments, had a care plan that incorrectly included monitoring for a bruit and thrill of a fistula, which was not applicable to his current treatment method. The Minimum Data Set (MDS) coordinator acknowledged that the care plan had not been updated to reflect the use of a CVC instead of a fistula. Resident 38, who managed her diabetes by checking her blood glucose levels and self-administering insulin, did not have a care plan that reflected these self-care activities. Despite having a physician order for blood glucose monitoring and insulin administration, there was no physician order for medication self-administration, and the care plan did not document her self-management of diabetes. The facility's Person Centered Care Plan policy, which lacked proper identification and was outdated, did not ensure the care plans were accurately revised to reflect the residents' current needs.
Deficiencies in Resident Record Documentation and Physician Notification
Penalty
Summary
The provider failed to ensure complete and accurate documentation in the resident records for four sampled residents. For Resident 20, the electronic medical record (EMR) indicated that the physician should be notified for blood sugar levels greater than 401, yet there was no documentation confirming that the physician had been notified after a reading above this threshold was recorded. Similarly, Resident 22's EMR showed multiple instances of blood sugar readings above 351 without documentation of physician notification. Resident 34's EMR contained incorrect information referring to another resident, and Resident 38's EMR included documentation errors with references to other residents and lacked evidence of physician notification for abnormal blood sugar levels. Interviews with facility staff, including the Executive Director (ED), Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed a lack of written policies on hypoglycemia management or diabetic care, and inconsistencies in documentation practices. The facility's policy on Resident's Access to Protected Health Information (PHI) was outdated and did not address the accuracy of resident records. The survey team noted these deficiencies during an exit conference with the ED and DON, who did not provide any disagreement or comment on the findings.
Failure to Document Power of Attorney for Healthcare
Penalty
Summary
The provider failed to ensure that a resident had proper documentation of a power of attorney for healthcare, which would have allowed information to be released to the resident's friend. The resident, who had a severe cognitive impairment with a BIMS score of 7, had a friend listed as a contact for care conferences and as an emergency contact. Despite this, there was no documentation indicating that the friend was authorized to make medical treatment decisions or receive medical information on behalf of the resident. The friend had given verbal consent for vaccinations and had been informed about medication changes, but these actions were not supported by a formal power of attorney for healthcare. Interviews with the social services director, regional nurse consultant, and director of nursing revealed a lack of awareness regarding the necessity of having proper documentation in place for releasing medical information. The facility's advanced directives policy outlined the importance of having documents such as a Durable Power of Attorney for Health Care, but this was not adhered to in the case of the resident. The staff acknowledged that the emergency contact was not listed as a power of attorney and that releasing information without proper documentation could potentially violate HIPAA regulations.
Failure to Re-weigh Resident and Incomplete Medication Self-Administration Assessment
Penalty
Summary
The provider failed to ensure that a resident was re-weighed after experiencing a significant weight loss. Resident 11's electronic medical record showed a weight drop from 165 pounds to 156 pounds over 13 days, a 5.45% decrease. Despite the facility's policy requiring re-weighing under nurse supervision for a weight change of three or more pounds, there was no documentation of a re-weigh. Interviews with staff revealed issues with scales and confirmed that the resident had not been re-weighed, nor was there documentation of the resident refusing to be weighed. Additionally, the provider did not accurately assess a resident for self-administration of medication. Resident 38, who had a BIMS score indicating cognitive intactness and a history of diabetes, was self-administering insulin without a completed medication self-administration safety screen or a physician's order authorizing self-administration. Despite progress notes indicating the resident was independently managing her insulin, the necessary physician's order was absent. The facility's policy required a completed safety screen and physician's order before initiating self-administration, which was not adhered to in this case.
Failure to Renew PRN Lorazepam Order
Penalty
Summary
The provider failed to ensure that a resident's as-needed (PRN) lorazepam order was renewed for use beyond 14 days. The electronic medical record (EMR) for the resident showed multiple orders for lorazepam to be administered as needed for anxiety, with varying dosages and frequencies. These orders were active until a specific date, after which they were not renewed, leading to a lapse in the medication regimen. During an interview with the regional nurse consultant, director of nursing, and assistant director of nursing, it was revealed that they were unaware that the PRN lorazepam orders had not been renewed. They acknowledged that the orders were not current and subsequently obtained a new order for the medication. The facility's policy on PRN psychotropic medication emphasizes the importance of managing the resident's medication regimen to promote their highest practicable well-being and requires that PRN anti-psychotic medications be limited to 14 days unless renewed following a direct examination by the prescriber.
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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