St William's Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milbank, South Dakota.
- Location
- 103 N Viola St, Milbank, South Dakota 57252
- CMS Provider Number
- 435122
- Inspections on file
- 17
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at St William's Care Center during CMS and state inspections, most recent first.
A resident with MS, non-ambulatory status, a mild Braden risk score, and an existing unstageable left heel pressure ulcer had a care plan and MD orders requiring frequent repositioning, use of an air mattress and cushions, and heel boots each shift. Over multiple observations, the resident was seen in a wheelchair, recliner, and in bed for extended periods without heel boots or heel offloading, and staff did not reapply the heel boot after wound care. CNAs and a medication aide relied on CNA sheets that lacked specific instructions for heel boots and hourly repositioning in a chair, and one CNA reported only using heel boots in the wheelchair, not in bed or a recliner. The DON confirmed the ulcer originated after ACE wrap use for edema and acknowledged that the ordered repositioning frequency and care plan interventions were not being implemented.
Dietary staff failed to follow dietitian-approved menus and serving sizes for resident meals. A cook routinely served reduced portions of vegetables, side dishes, and protein without consulting the menu, used smaller scoops than required, and varied chicken portions based on resident gender, even when diet cards did not indicate small portions. Menu review showed required serving sizes of three ounces of protein and four ounces of vegetables or pureed items, with no formal small-portion diet, despite several residents requesting smaller portions. The dietary manager reported that staff were expected to use menu books and a binder with serving sizes, but a newly hired dietary aide, trained by the same cook, was also observed serving only two-ounce portions of mashed potatoes and ground beef instead of the ordered amounts.
Surveyors identified multiple food safety and sanitation failures, including staff using the same disposable gloves to handle surfaces and then directly touch RTE food and dishware, and a dietary aide preparing deli sandwiches for staff and residents without changing gloves or performing hand hygiene after leaving and re-entering the kitchen. Thermometer probes were stored in sanitizer containing food debris and were wiped on a cloth instead of being sanitized with alcohol wipes before checking food temperatures. The kitchen and walk-in cooler had heavy dust on vents, fans, ceilings, and light fixtures, and the commercial dishwasher had significant food scum and limescale buildup, with many missed deliming sessions and numerous undocumented dish machine temperatures despite policy requirements. Potentially hazardous foods were left at room temperature for extended periods, raw bacon was stored above RTE mashed potatoes, frozen beef patties were left uncovered in the freezer, and multiple expired or visibly spoiled items, including flavor extracts, food coloring, coffee syrups, relish, and dressing with apparent mold, were found in storage without appropriate dating or rotation.
Surveyors found that the facility failed to implement a formal water management program for Legionella. The maintenance director maintained the in-line water heater at 117–118°F, below the 122–125°F range required for Legionella control, did not add chemicals for Legionella prevention, did not test building water for chlorine, and had no documented plan for flushing stagnant water in empty rooms. A city water employee confirmed chlorine testing was done only at an upstream site, not at the facility. The DON/infection preventionist and the administrator both stated they expected maintenance to follow federal Legionella guidelines, but the administrator acknowledged that staff turnover led to no monitoring, no formal process for flushing stagnant water, and no system to ensure appropriate water temperatures. The Infection Prevention and Control Policy in effect did not address Legionella management or prevention, creating a facility-wide deficiency with potential impact on all residents, staff, and visitors.
A resident received fast-acting insulin from an LPN before breakfast, and despite staff expectations that the resident would be awakened, have the meal tray set up, and eat within 20–30 minutes, observations later that morning showed the resident still asleep with an untouched tray and no documented blood glucose monitoring. In a separate case, another resident routinely wore bilateral compression stockings applied by staff for lower extremity edema, but review of the EMR and TAR showed no active MD order for the stockings despite prior related orders being discontinued, and the DON confirmed an order and treatment entry should have been present; the facility also lacked a policy for transcribing and communicating MD orders.
Surveyors found that medications and medical supplies were not properly stored, labeled, or secured. In the medication room, multiple expired respiratory test swabs, wound culture supplies, catheter drainage bags, self-cath kits, female straight catheters, and emergency airway/oxygen items in the code box were present, even though the code box had been used on a resident the previous day. On two medication carts, several residents’ insulin pens and inhalers were opened or in use but not dated, and two opened glucose test strip bottles were also undated. Staff, including an LPN/DON in training and the DON, described expectations that insulin pens and inhalers be dated and carts checked regularly, while a pharmacist confirmed insulin should be dated once removed from refrigeration. Surveyors additionally observed two medication carts left unlocked and unattended in hallways, one with a resident sitting in front of it, despite facility policy requiring carts to remain locked or under visual control when not in close proximity.
A resident with Alzheimer’s disease, moderate cognitive impairment, a prior elopement, and a care plan requiring a wander guard and frequent checks exited the building unsupervised after the wander guard system alarmed. Although alarms sounded at the exit door, at a panel, and alerts were intended for staff radios, on-duty staff did not promptly respond because some were not near the panel, some did not hear or carry radios, and one staff member had a radio on the wrong channel. Other staff, including a ward secretary and a travel CNA who had not been re-educated, were observed silencing door panel alarms after only reviewing cameras or without understanding the alarm’s purpose, and did not physically check doors. Documentation showed the resident’s wander guard checks were either missing or performed only once daily despite orders for three checks per day, and interviews revealed inconsistent staff understanding of elopement procedures and alarm response.
A resident with heart failure and intact cognition was observed independently applying NC oxygen and using an oxygen concentrator set at 1.3 L/min, despite no physician order for supplemental oxygen following readmission. Staff and record review showed only an order to check oxygen saturation three times daily and to withhold oxygen if saturation was above 90%, with no order specifying NC use, flow rate, or parameters for when to initiate oxygen. CNAs relied on nurses for concentrator settings, and a CNA pocket care plan simply stated the resident was to have oxygen at all times. The resident’s room lacked an “oxygen in use” sign, and there were no orders or documentation for changing NC tubing or cleaning the bubbler, contrary to the facility’s oxygen therapy policy requiring signage and weekly humidifier/bubbler cleansing.
A resident with PTSD had a completed PASRR Level II review approving a time-limited stay, but this determination was not incorporated into the resident’s MDS comprehensive or quarterly assessments, which both indicated no PASRR Level II had been done. The SW completed and kept PASRR documentation in her office, did not share it with the IDT or the RN/MDS coordinator, and believed she only needed to communicate PASRR recommendations. The RN/MDS coordinator reported there was no process to identify completed PASRR Level II reviews and was unaware that the SW completed them, resulting in the PASRR Level II not being reflected in the MDS despite facility policy requiring PASRR approval prior to admission.
The facility failed to ensure the medical director attended and meaningfully participated in QAA meetings at least quarterly as required. The administrator reported that the QAA committee meets monthly and that she routinely texted the medical director reminders; he usually replied with topics for discussion and only occasionally joined by phone. Documentation showed the medical director attended one meeting in person and one by telephone during the review period, while for all other months he either did not attend or only sent topics via text. Facility policy identified the medical director as a QAA committee member and required the committee to meet at least quarterly.
An incident of alleged staff-to-resident sexual abuse occurred when a CNA was rough while cleaning a resident, causing pain inappropriately. The resident, who was cognitively intact, reported the incident, leading to the CNA's suspension and termination. Despite the report, there was no indication of new interventions or recent abuse education for staff. The facility's response included notifying relevant parties and conducting an investigation, but gaps in documentation and communication were noted.
The facility failed to provide timely Medicare notices for two residents discharged from skilled services. One resident's SNF ABN was completed a day before the end of services, and the NOMNC form was outdated. Another resident's SNF ABN was completed on the last day of coverage, also using an outdated NOMNC form. The social services designee was aware of the 48-hour notice requirement but not of the outdated forms.
Two residents experienced medication administration errors due to an LPN not following physician orders, resulting in a 5.13% error rate. The LPN administered incorrect doses of naproxen sodium and brimonidine tartrate, intending to verify the correct doses with the physician later. The DON expected staff to verify orders before administration, but the facility's policy lacked guidance on handling dosing discrepancies.
The facility failed to serve room trays at satisfactory temperatures, with residents reporting cold meals. Observations showed delayed meal service and test trays confirmed inappropriate food temperatures. Staff interviews revealed poor communication and documentation of food complaints.
A resident was transferred to the hospital without receiving a bed-hold notice, as required by facility policy. Interviews revealed confusion over responsibility for issuing the notice, and policy reviews showed inconsistencies in bed-hold procedures.
A CNA in a LTC facility was reported to have verbally and physically abused three residents, including telling a resident to 'shut up' and forcefully sitting another resident back into a wheelchair. The incidents were not documented in the residents' progress notes, and their families were not informed. The facility's policies on abuse and neglect were not adequately followed, and communication among staff was insufficient.
A housekeeper in an LTC facility wrongfully took a resident's clothes without permission, violating the resident's rights. The clothes were found in the housekeeper's closet, and the family had not agreed to discard them. The housekeeper admitted to taking the items, claiming they were donated and not new.
The facility failed to report two incidents of alleged abuse involving two residents to the required entities within the required timeframe. Although a CNA was aware of the correct reporting procedures, the incidents were not reported to the South Dakota Department of Health as mandated by the facility's policy. The administrator was informed of the incidents but did not take the necessary steps to report them.
The facility failed to investigate two reported allegations of abuse involving a CNA and two residents. The administrator was informed of the incidents but did not report them to the required entities or conduct a thorough investigation, citing confidentiality concerns. The facility's policy requires immediate reporting and investigation of such incidents, which was not followed in this case.
A facility failed to securely store Tramadol, a controlled medication, for a resident. Interviews and observations revealed that Tramadol was kept in a single-locked drawer with other scheduled medications, contrary to the facility's policy requiring double-lock storage. The director of nursing acknowledged this practice did not comply with their Controlled Substance-Narcotic Medication Management Policy.
Failure to Implement Ordered Heel Offloading and Repositioning for Resident With Unstageable Heel Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow pressure ulcer prevention and treatment interventions for a resident with an existing unstageable pressure ulcer on the left heel and identified risk for pressure injury. The resident had multiple sclerosis, was non-ambulatory and confined to bed or chair, and had Braden scores of 16–17 indicating mild risk. Her care plan, initiated 12/9/25, documented fragile skin, an existing unstageable left heel pressure injury, and directed staff to reposition her at least every hour when in a chair and every two hours at night in bed, and to use pressure-reducing devices including an air mattress, wheelchair/recliner cushion, and heel boots to the left foot as needed. Physician orders included daily wound cleansing and moisturizing cream to the left heel and an order from 8/2/22 for heel boots to be placed every morning, afternoon, and night shift. Surveyor observations over multiple days showed the resident repeatedly seated or lying without heel boots or other heel offloading while remaining in the same position for extended periods. On several occasions, she was observed in her wheelchair or recliner for hours without heel boots, and at one point lying in bed on her back with no heel boots or pillows to offload her heels, remaining in the same position for approximately two and a half hours. During a wound care observation, the DON and wound nurse removed the heel boot to perform care and did not reapply it afterward. Staff interviews confirmed that the wound nurse had instructed staff to leave the heel wound open to air and use a heel boot for cushioning, but this was not consistently done. Additional interviews and record review revealed systemic gaps in communicating and implementing the resident’s pressure ulcer interventions. CNAs and a medication aide reported relying on CNA sheets for direction on repositioning and use of pressure-relieving devices. The CNA sheet for this resident did not include her specific pressure ulcer interventions, such as hourly repositioning in a chair or the need for heel boots, and only directed staff to monitor skin, lay her down after meals, use an air mattress, and place a cushion in her chair. One CNA stated she only applied heel boots when the resident was in her wheelchair and did not understand the need for them in bed or a recliner. The DON acknowledged that the resident’s heel ulcer began as a blister associated with ACE wrap use for edema and stated that residents should ideally be repositioned every two hours, also acknowledging that the care plan directive for hourly repositioning in a chair was not being followed and that care plans should reflect current care needs.
Failure to Follow Dietitian-Approved Menus and Serving Sizes for Resident Meals
Penalty
Summary
The deficiency involves dietary staff failing to follow dietitian-approved menus and prescribed serving sizes for residents’ meals. During a lunchtime observation in the kitchen, a cook reported that most residents requested smaller portions and stated she typically served about four ounces of meat and two ounces of vegetables or side dishes, without referencing the dietitian-approved menu to verify correct serving sizes for each prescribed diet. In the dining room, the same cook was observed using a four-ounce scoop for peas and two-ounce scoops for pureed peas, stewed tomatoes, and mashed potatoes, but only serving one two-ounce scoop of these items instead of the menu-required four ounces. She also served smaller chicken legs to female residents and larger bone-in chicken breasts to male residents, and provided one resident with one scoop of peas (about four ounces), one scoop of mashed potatoes (about two ounces), one scoop of gravy (about two ounces), one slice of bread, and one small chicken leg, despite the resident’s laminated diet card not indicating any request for small portions. Review of the dietary extension menus showed that the menu for the observed day required three ounces of protein, a half-cup (four ounces) of mashed potatoes, and a half-cup of stewed tomatoes or peas, including a half-cup of pureed peas for residents on pureed diets, and that there was no designated small portions diet. A diet orders report indicated that seven residents had requested small portions and two residents were on pureed diets. The dietary manager stated that staff were expected to use a menu book and a binder labeled “Cold Orders” that contained menus and serving sizes for each diet, and that all dietary staff should know how to access and use these diet menu spreadsheets. On a separate observation day, a newly hired dietary aide was seen using a two-ounce scoop for mashed potatoes and ground beef and serving only one scoop of each to residents, after being helped with hot-holding table setup by the same cook. Review of the provider’s menu for that day showed that residents should have received a half-cup (about four ounces) of mashed potatoes and three ounces of roast beef or ground beef for mechanical soft diets, which was not followed.
Widespread Food Safety, Sanitation, and Documentation Failures in Dietary Services
Penalty
Summary
The deficiency involves multiple failures in food handling and glove use, thermometer sanitation, kitchen cleanliness, dish machine temperature monitoring, food storage, and disposal of expired or spoiled food. During breakfast and lunch meal service, a cook and dietary aides wore single-use gloves but did not change them between tasks or after touching potentially contaminated surfaces. With the same gloves, they handled serving utensils, laminated diet tickets, serving tables, aprons, cart handles, and then directly touched food-contact surfaces of plates, slices of toast and bread, and the drinking surfaces of cups. One cook also scooped loose brown sugar into containers with a gloved hand instead of using a utensil. Another dietary aide prepared deli sandwiches for staff and residents, touching bread, sandwich meat, cling wrap, and a permanent marker, then left the kitchen and returned to continue food preparation without changing gloves or performing hand hygiene, despite facility policies stating that gloved hands are a food-contact surface that can become contaminated and that gloves must be changed when soiled or when interruptions occur. The facility also failed to properly store and sanitize food thermometers and maintain a clean and sanitary kitchen environment. Two thermometer probes were stored in a cup of sanitizer solution that contained visible food debris and had not yet been changed from the previous day. Later, when checking the temperature of chicken, the cook wiped a thermometer probe on a cloth sitting on top of a container of papers instead of using available alcohol wipes, contrary to the dietary manager’s expectation that probes be cleaned with alcohol wipes before use. Observations in the kitchen and walk-in cooler revealed thick dust on ceiling vents above the walk-in cooler and freezer, dust accumulation on all four cooler fans and their grates, and dust on the cooler ceiling and light fixtures. The commercial dishwasher had a thick layer of food scum and limescale buildup on the inside of the doors and under the seam where it connected to the dirty dish table, and deliming records showed that several scheduled cleanings from July to December were missed, with only one deliming completed in December. Dish machine temperature logs showed numerous missed entries over several months, despite a policy requiring staff to monitor and record wash and rinse temperatures at each meal and for the director of food and nutrition services to spot-check the logs. From August through mid-February, there were repeated omissions in documenting required temperatures, and a dietary aide assigned to dishwashing duties stated he did not check the dish machine temperature and could not recall the last time he had done so. Food storage practices were also deficient. Cooked beef tips in gravy and beef patties intended for lunch were left on the counter at room temperature from before breakfast service until mid-morning, with measured temperatures in the danger zone, and the cook confirmed the food had been sitting out since before breakfast service began. In the walk-in cooler, raw bacon was stored in a box above RTE mashed potatoes, and in the walk-in freezer, a box of frozen beef patties was left uncovered and open to the air. Additionally, several baking ingredients and flavoring agents on a shelf were past their manufacturer best-by or expiry dates, and in the walk-in cooler, a jug of sweet pickle relish had a lid that was not fully secured and had an unidentified white substance on the inside, while a jug of thousand island dressing had apparent mold on the outside of the container, inside the lid, and on the handle, with no open date marked. The dietary manager stated she was unaware of these expired and potentially moldy items, despite a policy requiring rotation, dating, and monitoring of food to ensure timely use or disposal.
Failure to Implement Legionella Water Management Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the absence of a water management program to mitigate the growth and spread of Legionella. The maintenance director reported that he checked the in-line water heater temperature every morning and maintained it at 117–118°F, despite the requirement for water temperatures to be 122–125°F for Legionella control. He also stated that no chemicals were added to the water for Legionella prevention, the building’s water was not tested for chlorine levels, and there was no formal plan or documentation for flushing stagnant water in empty rooms, even though he or housekeeping sometimes ran the water and flushed toilets. Review of water heater temperature logs from November 2025 through February 2026 showed the water heater was consistently maintained at 117°F. A city water employee confirmed that chlorine testing was performed daily at a nearby upstream facility but not at this nursing home. The DON/infection preventionist stated she expected maintenance to follow federal guidelines for Legionella prevention, and the administrator similarly stated she expected maintenance to follow guidelines to prevent Legionella and acknowledged there had been a staff changeover with no one monitoring that the process was being done. The administrator further stated there was no formal process for running stagnant water or ensuring water temperatures were at levels needed to kill Legionella, and that she was responsible for ensuring the water management process was followed. Review of the facility’s Infection Prevention and Control Policy dated October 2025 showed it did not contain information regarding Legionella management and prevention. These findings demonstrated that the facility lacked a formal, implemented water management program for Legionella as part of its infection prevention and control program, with the potential to affect all residents, staff, and visitors.
Insulin Administration and Compression Stocking Orders Not Managed per Professional Standards
Penalty
Summary
The deficiency involves failure to ensure services met professional standards of quality for two residents. For one resident with diabetes, an LPN administered 5 units of Novolog, a fast-acting insulin, and 42 units of Toujeo, a long-acting insulin, when the resident’s blood glucose was 264 and before the resident had eaten breakfast. The LPN stated that after Novolog administration the resident should eat or drink within 20–30 minutes, and that staff were supposed to wake the resident, set up the room tray, and encourage eating. However, subsequent observations showed the resident remained asleep with an untouched breakfast tray at the bedside more than an hour after insulin administration, and the resident later reported that staff had not awakened her when the tray was delivered and that she had not eaten anything that day. A pharmacist and the DON both confirmed that food intake or blood glucose monitoring should occur within 20–30 minutes after Novolog administration, and the facility lacked an insulin administration policy. The second deficiency concerns failure to ensure a resident had a physician’s order in the EMR and on the TAR for compression stockings that staff were routinely applying. One resident was observed wearing bilateral compression stockings and reported staff put them on each morning to help with lower leg swelling. A CNA confirmed the resident was to wear bilateral compression stockings when out of bed for edema, but on a later observation the resident was not wearing them and stated staff had not applied them that morning. Review of the EMR showed prior and discontinued orders for TED hose, Ace wraps, and compression stockings, including an order to discontinue compression stockings after ankle measurements showed no change, and a later provider progress note referencing the resident going without compression stockings. There was no active physician order for compression stockings at the time staff were applying them, and the DON confirmed there should have been an order in the EMR and a corresponding treatment on the TAR. The facility did not have a policy regarding transcription and communication of physician orders to staff for implementation.
Improper Medication Storage, Labeling, and Security
Penalty
Summary
The deficiency involves failure to ensure medications and medical supplies were properly stored, secured, and labeled according to professional standards and facility policy. In the medication room, surveyors observed multiple expired medical supplies, including respiratory infection test swabs, a wound culture, urinary catheter drainage bags, self-catheterization kits, female straight catheters, and several emergency airway and oxygen delivery items stored in the code box. Staff reported the code box had been used the previous day on a resident. The LPN/DON in training stated that overnight nurses were responsible for checking outdates during downtime and that a medication aide checked weekly, and acknowledged that expired items should have been removed and that their sterility and function could not be guaranteed if used. On two medication carts, surveyors found multiple insulin pens and inhalers that were opened or in use but not dated, including insulin pens for three residents and inhalers for five residents, as well as two opened glucose test strip bottles that were not dated. The LPN/DON in training stated insulin pens should not be used past expiration and that insulin pens and inhalers were expected to be dated once opened, and that carts were to be checked weekly and by night nurses. Surveyors also observed two separate instances where medication carts were left unlocked and unattended in hallways, one with no staff nearby and another with a resident sitting in front of the cart, while the responsible RN and DON were in or approaching resident rooms. The DON initially stated she did not think insulin pens needed to be dated until used, but the consulting pharmacist stated insulin was to be dated once removed from the refrigerator. The facility’s Administration of Medication policy stated that medication carts should remain locked when the nurse is not in close proximity and that at least visual control must be maintained to prevent unauthorized access.
Failure to Respond to Wander Guard Alarms and Supervise an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident identified as at risk for elopement, who left the building unsupervised. On the evening of 9/18/25, the resident exited through the facility’s back door. The wander guard system activated, sounding an alarm at the door, at the alarm panel, and sending an alert to staff radios. However, staff did not respond promptly: no staff were in the area of the alarm panel, not all staff heard the radio alert, and the resident was ultimately noticed and reported by another resident’s family member who heard the alarm and contacted an off-duty staff member. That off-duty staff member then called the facility, and the on-duty nurse went out and brought the resident back inside. The resident involved had Alzheimer’s disease, a BIMS score of 9 indicating moderate cognitive impairment, a history of prior elopement, and a documented elopement risk assessment indicating she was at risk for elopement and should wear a wander guard and be checked frequently. Her care plan documented wandering, getting lost looking for her room, and wearing a wander guard on her walker, with staff instructed to monitor the wander guard and respond if she set off the alarm. The CNA sheets and a list in a binder identified her as wearing a wander guard. However, review of her treatment records from September and October 2025 showed no documentation that the wander guard was checked, and from November 2025 through mid‑February 2026, checks were only documented once daily at bedtime, despite an order for checks three times a day. Multiple interviews and observations showed inconsistent understanding and implementation of alarm and elopement procedures among staff. Some CNAs reported that when the door panel alarmed, they only reviewed cameras and silenced the alarm if they saw nothing suspicious, and did not always go to check the door. One ward secretary silenced an active alarm after reviewing cameras without physically checking any door. A travel CNA, who had not received education upon returning to the facility, silenced the alarm panel without knowing its purpose or investigating the cause. Staff reported varying beliefs about whether wander guard alerts went to radios, and some staff did not carry radios, had radios turned down, or had them on the wrong channel, resulting in missed alerts. The DON described expectations that nursing staff carry radios with adequate volume and that wander guard alarms at exit doors send alerts to radios, but also acknowledged that maintenance only checked door panels monthly and that the facility did not have a device to test wander guard function beyond checking placement. Education on elopement and alarm response was inconsistently provided, with documentation showing that not all staff received the elopement education in‑service.
Oxygen Therapy Provided Without Physician Order and Incomplete Oxygen Care Practices
Penalty
Summary
Surveyors identified a deficiency in which a resident was provided continuous supplemental oxygen via nasal cannula (NC) without a corresponding physician order following readmission from the hospital. Observations showed an oxygen concentrator in the resident’s room with attached NC tubing and a water-filled bubbler that were undated, with no indication of when they were provided or cleaned, and no “oxygen in use” sign posted outside the room. The resident, who had a diagnosis of heart failure and a BIMS score of 15 indicating she was cognitively intact, independently applied the NC and turned on the concentrator, which was set at 1.3 L/min, stating she was supposed to wear oxygen per her doctor’s order. During another observation, the resident again applied the NC and turned on the concentrator when the surveyor entered, and an LPN checked her oxygen saturation, which was 98%, but did not remove the NC or turn off the concentrator. Record review revealed an order on the treatment administration record (TAR) only to check the resident’s oxygen saturation three times daily and that supplemental oxygen was not needed if saturation was greater than 90%, but there was no physician order for oxygen via NC at 1 L/min if saturation was less than 90%, nor any orders to change the NC tubing or clean the bubbler. Staff interviews confirmed the absence of a physician order for oxygen therapy upon readmission and that CNAs relied on nurses to tell them how to set the concentrator. A CNA reported she was unaware of any specific oxygen order and only knew the resident was to have her NC on, and a CNA pocket care plan indicated the resident was to have “oxygen at all times,” without detailing parameters. The DON/infection preventionist stated the resident should have had an EMR order for oxygen via NC at 1 L/min if saturation was less than 90%, as well as TAR entries for weekly bubbler cleaning, twice-monthly NC tubing changes, and placement of an “oxygen in use” sign, which were not present. Policy review showed the facility’s oxygen therapy policy required an “OXYGEN IN USE” sign outside the room and weekly cleansing of the humidifier/bubbler, which were not being followed for this resident.
Failure to Integrate PASRR Level II Determination Into MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to incorporate a resident’s Level II PASRR determination into the MDS assessments and to coordinate this information with the interdisciplinary team. One resident with a diagnosis of PTSD was admitted to the facility and had both a comprehensive and a quarterly MDS assessment completed, each indicating that no PASRR Level II had been done. However, record review showed that the resident had, in fact, undergone a PASRR Level II review by the state’s contracted PASRR service, which approved a 180‑day stay with a specified end date. This PASRR Level II information was not reflected in the MDS, despite the facility’s admission policy requiring PASRR pre‑admission screening and approval for the appropriate level of care prior to admission. Interviews with staff revealed that there was no established process to ensure that completed PASRR Level II determinations were communicated to the RN/MDS coordinator or incorporated into the MDS. The social worker reported that she completed PASRR forms, kept them in her office, and did not share the completed PASRR documentation with the interdisciplinary team or the RN/MDS coordinator, stating that it did not occur to her that she needed to inform the MDS coordinator whether a resident was PASRR Level I or II. She indicated she only informed nursing of any PASRR recommendations and noted she had MDS permissions only for Section S. The RN/MDS coordinator confirmed there was no process to determine whether a PASRR Level II had been completed and that Section S does not trigger Section A of the MDS, and she was unaware that the social worker completed PASRR Level II reviews for residents.
Failure of Medical Director to Attend QAA Meetings at Least Quarterly
Penalty
Summary
The deficiency involves the facility’s failure to ensure the medical director attended and meaningfully participated in Quality Assessment and Assurance (QAA) committee meetings at least quarterly as required. During an interview, the administrator stated that the QAA committee meets monthly and that she texted the medical director each month to remind him of the meetings; he typically responded by texting topics for the committee to discuss and only sometimes attended by telephone. The administrator acknowledged she was aware that the medical director was required to attend at least quarterly and that he did not have a NP or PA to attend in his absence. Review of the QAA committee binder showed the medical director attended via telephone at the most recent meeting in late January 2026 and attended in person in mid-August 2025, but for all other months in 2025 he either did not attend or only sent texted topics instead of participating in the meetings. Review of the facility’s QAPI policy from July 2025 confirmed that the medical director was designated as a QAA committee member and that the committee was required to meet at least quarterly.
Alleged Staff-to-Resident Sexual Abuse Incident
Penalty
Summary
The report details an incident of alleged staff-to-resident sexual abuse involving a resident who was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The incident occurred when a certified nursing assistant (CNA) was cleaning the resident after she used the bathroom. The resident reported that the CNA was rough and caused pain by cleaning her vaginal area inappropriately. The resident expressed concern that the CNA's actions were intentional, as the CNA commented on the resident being dirty and needing to be cleaned to prevent infections. Following the incident, the resident was assessed by a licensed practical nurse (LPN) and subsequently transferred to a local emergency room for further evaluation. The facility's administrator and director of nursing (DON) were notified, and the CNA involved was suspended pending investigation and later terminated. Despite the resident's report, there was no indication of new or different interventions or care provided to her following the incident. Interviews with other staff members revealed a lack of awareness of any new interventions or recent abuse education, particularly regarding sexual abuse. The facility's response to the incident included notifying relevant parties and conducting an investigation. However, there were gaps in documentation and communication, as evidenced by the absence of a social services note in the resident's record and the lack of a completed SANE report. Additionally, there was no specific education or training on sexual abuse provided to staff following the incident, and the facility continued to use audits from a previous physical abuse incident. The report highlights the need for comprehensive abuse education and thorough documentation in handling such sensitive cases.
Failure to Provide Timely Medicare Notices
Penalty
Summary
The provider failed to ensure appropriate and timely Medicare notices were provided for two residents who were discharged from skilled services. For one resident, the Medicare Part A Skilled Episode began on 7/25/24, with the last covered day on 8/20/24. However, the SNF Advance Beneficiary Notice of Non-coverage (ABN) was completed on 8/19/24, not providing the required 48-hour notice prior to the end of services. Additionally, the Notice of Medicare Non-Coverage (NOMNC) form used was outdated and had an incorrect header. For the second resident, the Medicare Part A Skilled Episode started on 5/17/24, and the last covered day was 6/4/24, the same day the SNF ABN was completed and signed, again failing to meet the 48-hour notice requirement. The NOMNC form was also outdated and lacked the correct header. An interview with the social services designee revealed awareness of the 48-hour notice requirement but unawareness of the outdated forms.
Medication Administration Errors
Penalty
Summary
The provider failed to follow physician orders during medication administration for two residents, resulting in a medication error rate of 5.13%. For one resident, a licensed practical nurse (LPN) administered a 220 mg tablet of naproxen sodium instead of the prescribed 250 mg. The LPN acknowledged the discrepancy but proceeded to give the medication, intending to verify the correct dose with the physician later. In another instance, the same LPN administered one drop of brimonidine tartrate 0.2% solution into each eye of a resident, contrary to the physician's order of two drops per eye. Again, the LPN planned to confirm the correct dosing with the doctor after administration. The director of nursing (DON) stated that nurses are expected to verify physician orders with the medication administration records (MAR) before administering medications. The facility's policy on medication administration emphasized giving the correct medication at the appropriate dose and time but did not specify procedures for addressing discrepancies in dosing or orders. The lack of adherence to these protocols contributed to the medication errors observed during the survey.
Deficiency in Serving Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that room trays were served at a satisfactory temperature for residents who chose to eat meals in their rooms. Three residents reported that their meals were often cold by the time they were delivered. One resident mentioned that by the time her reheated food was returned, she had already finished the rest of her meal. Another resident, who was new to the facility, did not report the issue to staff to avoid causing trouble. The third resident also complained about cold food on his room tray. Observations during the survey revealed that the meal service in the dining room was delayed, with the first resident being served 27 minutes after the stated meal service time and the last resident 53 minutes later. The test trays delivered to the survey team showed that food items were not at appropriate temperatures, with some items being lukewarm or cold. The dietary manager acknowledged awareness of complaints about cold food on room trays and noted that the insulated carts work best if trays are served within 10 to 15 minutes. Interviews with staff revealed a lack of communication and documentation regarding food complaints. The dietary manager was not aware of complaints from the resident council meeting, and the social service designee did not keep records of verbal complaints or fill out concern forms for issues raised at the meetings. The administrator and DON were aware of the cold food complaints but did not use concern forms to document them. The policy on resident room trays was requested but not received by the end of the survey.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The provider failed to provide a bed-hold notice to a resident or their representative when the resident was transferred to the hospital. The deficiency was identified for one resident who was transferred to the hospital on August 13, 2024, and returned to the facility on August 19, 2024. Although the resident's power of attorney was notified of the transfer, there was no documentation that the bed-hold information was communicated to either the resident or their power of attorney. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing bed-hold notices. The social services designee stated that she had not received the bed-hold notice from the nurses and confirmed that it had not been completed. The director of nursing indicated that the social services designee was ultimately responsible for ensuring bed-hold notices were completed. A review of the facility's policies and admission documents showed inconsistencies and omissions regarding bed-hold procedures, particularly for Medicare residents.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The provider failed to protect three residents from mistreatment, intimidation, verbal abuse, and physical abuse by a certified nurse assistant (CNA). Resident 2, who was not feeling well and had vomited several times, was reportedly told to 'shut up' by CNA J and had her hands swatted away from her incontinence brief. This incident was witnessed by another CNA, although CNA J denied the allegations. Resident 2's medical records indicated she had anxiety disorder and dementia, which required specific care approaches that were not adhered to during the incident. Further incidents involved Resident 3 and Resident 4. Resident 3 was reportedly stuck behind a door, and CNA J was heard yelling and banging on the door. Resident 4, who had a history of falls and required assistance, was forcefully sat back into her wheelchair by CNA J after attempting to stand. This incident was witnessed by a nurse aide who reported that Resident 4 expressed fear towards CNA J, referring to him as 'a hateful person.' These actions were not documented in the residents' progress notes, and their families were not informed of the alleged abuse. The facility's policy on abuse, neglect, and misappropriation of resident property emphasizes the importance of treating residents with dignity and respect, and outlines procedures for reporting and investigating abuse. However, the incidents involving CNA J suggest a failure to adhere to these policies, as there were multiple reports of verbal and physical abuse that were not adequately addressed. The facility's investigation process and communication among staff were also found to be lacking, as evidenced by the administrator's failure to inform other department heads about the incidents.
Misappropriation of Resident Property by Housekeeper
Penalty
Summary
The provider failed to protect a resident's belongings from being wrongfully used by a housekeeper. On July 13, 2024, a bag of clothes belonging to a resident was found in the housekeeper's closet. The family of the resident had not given permission for the clothes to be discarded, indicating a violation of the resident's rights. Additionally, a shirt belonging to a recently deceased resident was also found in the same housekeeper's closet. The housekeeper admitted to taking the clothes without permission, claiming they were donated items and not new. The housekeeper had been previously spoken to about taking donated clothing home, which was intended for residents, not staff. The housekeeper stated that she did not obtain permission from the family through social services before removing items from resident rooms. This incident was reported to the administrator on July 15, 2024, and the required reporting was submitted on July 17, 2024. The failure to ensure the protection of resident property violated the resident's right to be free from misappropriation of property.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The provider failed to report allegations of abuse to the required entities within the required timeframe for two incidents involving two residents. A certified nursing assistant (CNA) was aware of the correct reporting procedures but had not reported any incidents recently. However, she was aware of two incidents involving another CNA and two residents, which were reported by a different CNA. The administrator was informed of these incidents by a nurse aide but did not report them to the South Dakota Department of Health (SD DOH) as required. The facility's policy mandates immediate reporting of alleged violations involving mistreatment, neglect, or abuse to the administrator and the SD DOH. Despite this, the incidents involving the two residents were not reported to the SD DOH or other required entities. The administrator acknowledged awareness of one incident and initially denied knowledge of the other but later recalled it. The facility's policy emphasizes the importance of reporting to prevent worsening situations or harm to residents, yet these procedures were not followed in these cases.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The provider failed to investigate two reported allegations of abuse involving two residents. The administrator was informed by a nurse aide about incidents involving a certified nursing assistant (CNA) being cross with residents. Despite being aware of the incidents, the administrator did not report them to the required entities or conduct a thorough investigation. The administrator admitted to not informing other department heads to maintain confidentiality and only informed the Director of Nursing (DON) about the situation. The administrator kept a daily log of conversations but could not recall when the incidents were reported. The facility's updated policy on abuse, neglect, and misappropriation of resident property outlines the process for identifying, investigating, and reporting alleged violations. The policy requires immediate reporting of incidents to the administrator and the South Dakota Department of Health, with specific timelines based on the severity of the incident. However, the administrator did not follow these procedures, failing to report or investigate the allegations involving the CNA and the two residents. The policy also emphasizes the protection of residents during investigations and the need for corrective actions if violations are verified.
Failure to Securely Store Controlled Medication
Penalty
Summary
The facility failed to adhere to its Controlled Substance-Narcotic Medication Management Policy by not securely storing a controlled medication, Tramadol, for a resident. During interviews, a medication aide revealed that Tramadol, a controlled substance, was stored in the same location as other scheduled medications and was not double-locked, contrary to the facility's policy. The aide acknowledged that while PRN controlled medications were stored in a double-locked drawer and counted at shift changes, scheduled controlled medications like Tramadol were not counted at shift changes and were not double-locked. Further interviews and observations confirmed that scheduled controlled medications, including Tramadol, were kept with other scheduled medications in a single-locked drawer of the medication cart. The director of nursing admitted that this practice did not comply with the facility's policy, which requires all scheduled II-V medications to be maintained in a separately locked, permanently affixed compartment. The policy also mandates that all controlled substances be counted at each shift change, which was not being followed for scheduled medications.
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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