Strand-kjorsvig Community Rest Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Roslyn, South Dakota.
- Location
- 801 S Main, Roslyn, South Dakota 57261
- CMS Provider Number
- 435125
- Inspections on file
- 15
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Strand-kjorsvig Community Rest Home during CMS and state inspections, most recent first.
The facility did not maintain consistent on-site administrative oversight, with the administrator of record only present weekly and a secondary administrator covering once a week while also managing another facility. Most day-to-day management and administrative duties were delegated to the DON and business manager, leading to difficulties in fulfilling their primary responsibilities and impacting the quality management and well-being of all residents.
The facility did not ensure its QAPI program effectively identified and corrected quality deficiencies, as the QAPI committee and DON were unaware of multiple areas of non-compliance, including medication management, care planning, assessments, oxygen equipment handling, trauma-informed care, food storage, and infection control. The QAPI committee was only focused on a limited set of issues and failed to monitor or address several critical areas impacting resident care.
The QAA committee did not consistently include an administrator, owner, board member, or other leadership representative, as required. Over a 15-month period, the administrator attended only two meetings, and no other leadership figures were present, despite policy stating their responsibility for QAPI oversight. Department managers, the medical director, and the consultant pharmacist attended, but leadership involvement was lacking.
Several residents self-administered medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or required physician's orders. Medications were left at the bedside or in resident rooms, sometimes expired or unlabeled, and care plans did not address self-administration or medication storage. Facility staff confirmed that no residents had been formally assessed or authorized for self-administration, contrary to facility policy.
Several newly admitted residents did not have complete baseline care plans within 48 hours of admission, with missing documentation of review and provision to residents or their representatives. Some care plans lacked essential information such as active diagnoses and signatures, and residents reported not recalling any review or receipt of their care plans. The facility's policy did not require review of the baseline care plan with the resident or representative within the specified timeframe.
Surveyors found that care plans for several residents were not updated to reflect current care needs, including missing documentation of activity interests, therapy interventions, behavioral health strategies, self-administration of medications, and use of medical devices. Staff interviews revealed a lack of awareness and formal auditing of care plans, and facility policies requiring individualized, interdisciplinary care planning were not consistently followed.
A resident receiving antipsychotic medication did not receive a timely AIMS assessment as ordered by the physician, and the results were not communicated. Additionally, a resident with diabetes had multiple insulin doses held due to low blood sugar or lack of appetite, but the physician was not consistently notified, and there was no clear policy guiding these notifications. These actions resulted in deficiencies related to following physician orders and ensuring professional standards of quality.
The facility did not consistently follow its own policies for counting and documenting controlled medications, including those in emergency kits and those prescribed to individual residents. Required shift-to-shift counts and verification of tamper-evident tag numbers were frequently incomplete or missing, with forms lacking staff initials, tag numbers, and documentation for entire shifts. Staff and the DON confirmed gaps in documentation and acknowledged the absence of a system to record counts for individual residents' controlled medications, despite facility policies mandating these procedures.
Surveyors found that medications with shortened expiration dates were not properly labeled or disposed of after expiration, and expired medications remained in use. Medication labels often did not match current physician orders as documented in the MAR, and there was no consistent process to indicate dose changes on medication containers. Additionally, daily temperature monitoring and documentation for medication storage areas, including refrigerators, were incomplete or showed temperatures outside the acceptable range. Staff were aware of some requirements but did not consistently follow policies for medication management.
The facility did not ensure Enhanced Barrier Precautions (EBP) were followed for two residents with wounds, as required by its infection control policy. PPE such as gowns and gloves were not available at the point of care, staff inconsistently used PPE during high-contact activities, and there was confusion among staff about when and where EBP should be applied, including in therapy areas.
The facility did not follow its antibiotic stewardship policy, as the DON admitted to inconsistent use of required infection surveillance forms, lack of documentation of symptoms before contacting physicians, and failure to monitor infection trends or conduct required audits. The facility also did not complete annual summaries, hold stewardship meetings, or maintain an antibiogram, and the DON was unaware of elevated UTI rates among long-stay residents.
The designated infection preventionist, who was the DON, had not completed the required CDC infection prevention and control training, having finished only 5 of 23 modules and lacking a certificate of completion.
Surveyors found that two residents using respiratory devices did not receive proper infection control, cleaning, or documentation as required by facility policy. One resident's nebulizer was stored on the floor and not cleaned after each use, while another resident's CPAP lacked a physician order, care plan inclusion, and documented cleaning. Staff interviews revealed inconsistent practices and knowledge, and facility policies were not aligned with actual procedures.
Two residents with PTSD and moderate cognitive impairment were not assessed for trauma-related needs, and their care plans lacked interventions or strategies to address their mental health conditions. Staff interviews confirmed the absence of a trauma-informed care policy or assessment process, and documentation of mental health services was missing despite facility policy requirements.
Surveyors found that opened food containers in the kitchen were not dated and expired food items were not discarded, including undated cereal and expired cheese that had physically deteriorated. The dietary manager was unaware of these issues, despite facility policies requiring regular inspection, labeling, and removal of expired products.
A resident with a history of mental health issues was able to hide and later ingest multiple doses of Tylenol due to staff failing to supervise her medication intake. This resulted in her hospitalization for hypotension and liver failure. The facility's policy required staff to remain with residents during medication administration, which was not followed in this case.
A resident with a history of mental health issues was able to accumulate Tylenol tablets due to staff failing to ensure medication consumption, leading to a self-harm incident and hospitalization. The facility's policy required staff to remain with residents until medications were swallowed, which was not followed.
Inadequate Administrative Oversight and Delegation of Duties
Penalty
Summary
The facility failed to ensure effective and efficient use of its resources due to inadequate administrative oversight and inconsistent presence of the administrator. Administrator A, who was the administrator of record, was only present in the building weekly, and when unavailable, administrator B, who was also a full-time administrator at another facility, would be present once a week. Department managers such as the DON, business manager, and dietary manager were expected to be in the building full-time, but significant administrative duties were delegated to the DON and business manager. The DON reported struggling to fulfill her nursing responsibilities while also covering administrative tasks, and noted that administrator A's response to issues was not always timely. The business manager was unavailable during the survey for interview. Interviews with staff revealed that the day-to-day operations and quality management of the facility were largely handled by the DON and business manager, with administrators only intervening when issues arose that could not be addressed by these managers. The administrator job description required direct oversight and accountability for the facility's operations, but this was not consistently met. The lack of regular, on-site administrative supervision led to management issues being delegated to department heads, impacting their ability to perform their primary roles and potentially affecting the overall well-being of the 26 residents in the facility.
Failure to Identify and Address Quality Deficiencies Through QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified and corrected quality deficiencies throughout the facility. The Director of Nursing (DON) was responsible for overseeing the quality management program, including QAA committee meetings and QAPI projects. However, during an interview, the DON stated that while each department manager conducted audits and discussed them with the QAPI committee, the committee was only focused on a limited set of issues such as restraints, skin infections, call light accessibility, and communication with medical providers regarding lab results. The DON was unaware of several areas of non-compliance, including medication administration and storage, timely provision of baseline care plans, accurate care plan revisions, completion of required assessments, proper handling of oxygen equipment, trauma-informed care assessments, safe food storage, and infection prevention and control practices. The QAPI committee had not identified or addressed these significant quality issues, and the DON confirmed that the QAPI process had not been effective in identifying problems that could impact resident care. The facility's QAPI policy stated that the program should encompass all care and services affecting clinical care, quality of life, resident choice, and care transitions, and that the governing body and management were responsible for identifying and prioritizing problems based on performance data. Despite this, the QAPI committee was not aware of or monitoring several critical areas of deficiency, as confirmed by the DON.
QAA Committee Lacked Required Leadership Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee included the required members, specifically an administrator, owner, board member, or other individual in a leadership role, as mandated. Over a 15-month period, attendance records showed that the administrator attended only two QAA meetings, and there was no evidence that the owner, a board member, or another leadership designee attended any meetings. Interviews with the medical director and DON confirmed that the administrator was not routinely present at QAA or QAPI meetings, and the DON noted that the administrator had only recently attended a meeting after a prolonged absence. The QAA committee was otherwise comprised of department managers, the medical director, and the consultant pharmacist, but lacked consistent leadership representation. The facility's QAPI policy outlined that the governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program, including identifying and prioritizing problems, incorporating input from staff and residents, and ensuring corrective actions are effective. Despite these policy requirements, the facility did not provide evidence that leadership was actively involved in the QAA process during the review period, as required by regulation.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications were properly assessed for their ability to do so safely and did not obtain the required physician's orders for self-administration, as outlined in facility policy. Four residents were identified as self-administering medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or care plan interventions addressing their ability to self-administer. In several cases, medications were left at the bedside or in resident rooms without proper labeling or documentation, and some medications were expired or not prescribed for current use. One resident with moderate cognitive impairment was observed self-administering nebulizer treatments and using topical medications left at his bedside, including an expired antibiotic ear drop that he used for itching. He also had an antacid medication left at his bedside for self-administration without a physician's order or assessment. Another resident, who was cognitively intact, self-administered prescription cream and powder with physician's orders to keep the medications in his room, but there was no documentation of an assessment for his ability to self-administer these medications, nor was this addressed in his care plan. Additional residents were found to have medications such as Vicks Vapor Rub and nebulizer treatments in their rooms, which they self-administered without physician's orders or documented assessments. Facility staff, including LPNs and the DON, confirmed that no residents had been formally assessed for self-administration of medications and that physician's orders for self-administration were not in place. The facility's policies required both an assessment and a physician's order for self-administration, but these procedures were not followed, and the care plans did not address self-administration or medication storage for the affected residents.
Failure to Complete and Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and document baseline care plans and provide written summaries to residents or their representatives within 48 hours of admission for four recently admitted residents. Record reviews showed that baseline care plans were either incomplete, missing required sections such as active diagnoses, staff and resident signatures, or not documented as being reviewed with the resident or their representative. In several cases, there was no evidence that a copy of the baseline care plan was offered or provided to the resident or their representative. Interviews with the residents revealed that they did not recall reviewing their care plans or being offered copies within the required timeframe. Specific observations included residents with moderate cognitive impairment, use of medical devices such as CPAP machines and equalizer boots, and recent hospitalizations. The facility's policy required an interim plan of care to be developed within 24 hours of admission but did not specify that the plan must be reviewed with the resident or representative within 48 hours. The DON confirmed that several baseline care plans were incomplete and lacked documentation of review or provision to the residents or their representatives.
Failure to Update and Individualize Resident Care Plans
Penalty
Summary
Surveyors identified that the facility failed to ensure care plans were reviewed and revised to reflect the current care needs for seven of twelve sampled residents. Multiple observations, record reviews, and interviews revealed that care plans did not include essential information about residents' current conditions, interventions, and preferences. For example, one resident who spent significant time working on puzzles and was preparing for discharge had no documentation in his care plan regarding his activity interests or discharge plans. Another resident, who was on a therapy maintenance and positioning program requiring her feet to be elevated in a recliner, had no mention of this intervention in her care plan, and the director of nursing was unaware of the program's existence for this resident. Additional deficiencies were noted for residents with complex behavioral and medical needs. One resident with severe anxiety, pacing, and crying behaviors had no documentation in her care plan of non-pharmacological interventions or updates regarding the removal of bed rails, despite ongoing behavioral symptoms and changes in her care. Another resident self-administered topical medications as ordered by a physician, but this was not addressed in his care plan. Residents with mental health diagnoses, such as PTSD and major depressive disorder, also had care plans lacking interventions or strategies to address their specific behavioral health needs, including triggers and coping mechanisms. In one case, a resident's care plan did not reflect the use of a CPAP machine for obstructive sleep apnea, despite the resident's long-term use of the device. Interviews with staff, including the DON, LPNs, and social service designee, confirmed that care plan updates were primarily completed by the MDS nurse and that there was no formal audit process in place. Staff were often unaware of whether specific interventions or resident needs were included in the care plans. Facility policies required individualized, interdisciplinary care plans that addressed current needs and preferences, but these were not consistently followed, resulting in care plans that did not accurately reflect the residents' current care requirements.
Failure to Complete Physician-Ordered Assessments and Notify Physician of Held Insulin Doses
Penalty
Summary
A deficiency occurred when a physician-ordered Abnormal Involuntary Movement Scale (AIMS) assessment was not completed as required for a resident receiving antipsychotic medication. The resident, who was severely cognitively impaired and had diagnoses including Wernicke's Encephalopathy, anxiety disorder, amnestic disorder, and drug-induced subacute dyskinesia, exhibited abnormal movements such as hand tremors, constant leg movement, and restlessness. Despite a physician's order to complete an AIMS assessment and provide updates on mood, behaviors, and PRN Lorazepam use, there was no documentation that these assessments or communications were completed after the last recorded AIMS assessment. The DON confirmed that the required assessment and updates were not performed or communicated to the physician as ordered. Another deficiency was identified regarding the management of insulin for a resident with diabetes. The resident's insulin doses were repeatedly held due to low blood sugar readings or lack of appetite, but there was no physician order specifying parameters for when to hold insulin until later in the month. Documentation showed that the physician was not notified each time insulin was held, and staff interviews confirmed that notifications were not consistently made. The medical director stated that immediate notification was expected when insulin was held for hypoglycemia, but this did not occur. The facility lacked a policy specifically addressing physician notification for held or refused medications, and documentation of physician notification for the held insulin doses was not provided. Policy reviews revealed that while there were general protocols for physician visits, medication orders, diabetes management, and notification of resident changes, there were gaps in policies related to following physician orders unrelated to medications and specific guidance on physician notification for held or refused medications. The absence of clear documentation and communication with the physician regarding both the AIMS assessment and insulin management led to the deficiencies identified during the survey.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to follow its own policies and procedures for the management and documentation of controlled medications, specifically those stored in emergency kits (E-Kits) and in medication carts and refrigerators. Observations and interviews revealed that required shift-to-shift counts of controlled substances were not consistently documented by two staff members as required. Forms intended to record these counts and the verification of tamper-evident tag numbers on E-Kits were frequently incomplete, with missing staff initials, missing tag numbers, and days where no documentation was present at all. This pattern was observed across multiple months, with repeated instances of incomplete or missing documentation for both day and night shifts. Interviews with nursing staff confirmed that the expectation was for two staff members to count and document controlled medications at each shift change, including those in E-Kits and those prescribed to individual residents. However, staff acknowledged that there was no form or designated location to document the counts of controlled medications prescribed to individual residents, making it impossible to verify when or by whom these counts were completed. The Director of Nursing also confirmed this gap in documentation and was unaware of the frequency of missing or incomplete records for the E-Kit counts and tag verifications. Policy reviews showed that the facility's own procedures required controlled substances to be counted and documented by two staff members at every shift change, with specific forms to be used for this purpose. Despite these clear requirements, the facility did not ensure that documentation was complete or that all required counts were performed and recorded, resulting in a failure to properly account for controlled medications as mandated by facility policy.
Medication Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and administration of medications and biologicals. Medications with shortened expiration dates, such as inhalers and eye drops, were not consistently labeled with their opened or expiration dates, and some expired medications remained in medication carts for potential use. For example, opened Latanoprost eye drops and Trelegy Ellipta inhalers lacked proper documentation of opened and expiration dates, and expired Latanoprost eye drops were still present in the cart. Additionally, a stock supply of Silver Sulfadiazine cream was found to be opened for over a year without being discarded. There were discrepancies between medication labels and the current physician orders as documented in the medication administration records (MARs). Several medications, including gabapentin, midodrine, duloxetine, and insulin pens, had pharmacy labels that did not match the MARs, and there was no indication on the medication containers that the orders had changed. Staff, including LPNs and certified medication aides, reported that pharmacy did not replace labels when orders changed, and there was no consistent process to indicate dose changes on medication containers. This inconsistency made it difficult for staff to verify correct medication doses during administration. Temperature monitoring and documentation for medication storage areas were also found to be deficient. The refrigerator used to store medications had multiple days with missing temperature documentation throughout the year, and several days with recorded temperatures outside the acceptable range. The facility did not monitor or document the temperature of the room where medications were stored, contrary to policy requirements. The DON confirmed awareness of some issues, such as the need to date medications when opened, but was not aware of the extent of missing or out-of-range temperature documentation.
Failure to Implement Enhanced Barrier Precautions According to Policy
Penalty
Summary
Surveyors identified that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own infection prevention and control policy for two residents who were on EBP. Observations revealed that signage indicating EBP was present on the doors of both residents, but there was no personal protective equipment (PPE) such as gowns or gloves available at or near the entrances to their rooms. Staff interviews confirmed inconsistent understanding and application of EBP, with some staff unaware of the reasons for EBP signage or the correct PPE requirements, and others storing gowns in resident dressers or closets rather than at the point of care. For one resident, who had recently returned from the hospital with a surgical incision and staples, there was no documentation in the electronic medical record (EMR) indicating the need for EBP, and the resident herself was unaware of the reason for the precautions. For the second resident, who had a surgical wound on his right lower leg requiring daily dressing changes, staff wore gloves but not gowns during care, and PPE was not accessible at the room entrance. The care plan for this resident specified that both gloves and gowns should be used for high-contact activities, but this was not consistently followed. Further observations in the therapy area showed that staff did not use PPE when providing direct care, such as assisting with transfers and mobility, to residents on EBP. Interviews with therapy and nursing staff revealed gaps in knowledge regarding when and where PPE should be used, particularly outside of resident rooms. The facility's policy required EBP, including gown and glove use, during high-contact activities both in resident rooms and in shared areas like the therapy gym, but this was not adhered to in practice.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as outlined in its own policy. The Director of Nursing (DON), who also served as the infection preventionist, acknowledged that the facility was not consistently using the SBAR form based on McGeer criteria for infection surveillance, particularly for suspected urinary tract infections (UTIs). The DON admitted that staff often bypassed the required documentation of symptoms before contacting physicians, and the facility was almost always noncompliant with this process. Additionally, the DON did not monitor infections by resident location to identify potential clusters and only reviewed monthly antibiotic use reports from the contracted pharmacy, which lacked information on diagnosis or appropriateness of antibiotic use. Further review revealed that the facility did not adhere to several key components of its antibiotic stewardship policy. The DON did not complete an annual summary of antibiotic use, failed to hold antibiotic stewardship meetings, did not perform random audits of antibiotic prescriptions, and did not track at least one outcome measure associated with antibiotic use monthly. The facility also lacked an antibiogram, which is required to guide antibiotic use protocols, and did not provide annual feedback to prescribing physicians regarding their antibiotic use for residents. Documentation related to the stewardship program, such as meeting minutes and feedback reports, was not maintained as required by policy. The DON was unaware that the facility's infection rate for UTIs among long-stay residents was above state and national averages, as reported in the facility's quality measures. The facility's policies required the infection preventionist to report findings of surveillance activities, including infection rates and types, to the QAA committee, physicians, and other staff, but these activities were not being carried out as described. The facility's own assessment claimed that infections were tracked and trended, and that there were regular meetings to discuss infection control and antibiotic stewardship, but these practices were not substantiated by the DON's statements or by documentation.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that the designated infection preventionist, who was the Director of Nursing (DON), had completed the required specialized training in infection prevention and control. The DON was hired in October 2021 and began the CDC's Nursing Home Infection Preventionist Training course in October 2022. However, as of the time of the survey, the DON had only completed 5 out of the 23 required modules and was not aware that the course was incomplete. Record review confirmed the lack of a certificate of completion for the full course, and the DON acknowledged not having finished the training.
Deficient Infection Control and Documentation for Respiratory Devices
Penalty
Summary
Surveyors identified deficiencies in the facility's provision of safe and appropriate respiratory care for residents requiring respiratory devices, specifically related to infection control practices and documentation. For one resident using a nebulizer, the device was observed stored on the floor and the mask was hung on a tack between uses. The resident reported not cleaning the mask after treatments, and there was no documentation in the electronic medical record (EMR) regarding cleaning frequency, responsibility, or method. The facility's policy required cleaning after each use, but this was not consistently followed or documented. Another resident using a CPAP machine did not have a current physician's order for its use, and neither the initial nor current care plan addressed the CPAP or the resident's respiratory diagnoses. The resident reported that while nurses refilled the CPAP reservoir, the mask and tubing had not been cleaned since admission. There was also no documentation in the EMR regarding cleaning of the CPAP equipment, despite facility policy requiring weekly cleaning and documentation in the medication administration record (MAR). Interviews with staff, including an LPN and the DON, revealed inconsistencies in knowledge and practice regarding cleaning and documentation of respiratory devices. The DON was unaware of the lack of physician order, care plan documentation, and cleaning records for the CPAP. Additionally, facility policies related to cleaning and storage of respiratory equipment were found to be inconsistent and not always reflective of actual practices, contributing to the deficiencies observed.
Failure to Assess and Address Trauma-Informed Care Needs for Residents with PTSD
Penalty
Summary
The provider failed to assess and address the trauma-related needs of two residents diagnosed with post-traumatic stress disorder (PTSD). Both residents had moderate cognitive impairment and complex psychiatric histories, including anxiety, depression, hallucinations, and a history of chemical dependency. Despite these diagnoses, their care plans did not include specific interventions, triggers, or behavioral supports related to their PTSD or associated mental health conditions. One resident, a military veteran, had a documented incident where he struck another resident after being disturbed in his room, yet his care plan lacked any trauma-informed strategies or behavioral interventions. Additionally, there was no evidence that either resident was receiving scheduled or as-needed mental health services as indicated in their care plans. Interviews with facility staff, including the DON and LPNs, revealed that there was no policy or formal assessment process for trauma-informed care in place. Staff acknowledged that while trauma was noted at admission, there was no documentation or follow-up assessment, and interventions for PTSD were not identified or implemented in the care plans. The facility's own policy referenced the need to identify and implement interventions for residents with trauma or psychiatric diagnoses, but this was not reflected in practice. No trauma-informed care policy was provided when requested by surveyors.
Failure to Date Opened Food and Remove Expired Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food safety practices within the facility's kitchen. In the dry food storage room, there were opened containers of cereal that were not dated when opened. In the walk-in refrigerator, a carton of supplement and a package of shredded mozzarella cheese were found past their use-by and best-by dates, respectively. The mozzarella cheese had also physically deteriorated, condensing into quarter-sized balls. These observations indicate that food items were not consistently dated upon opening and expired items were not removed from inventory as required. During an interview, the dietary manager was unaware of the unmarked and outdated food items. He stated that it was his expectation for staff to date containers when opened and to use or discard food before expiration. The facility's policies require regular inspection of food products, proper labeling and dating of opened items, and adherence to FIFO (First In First Out) procedures. However, these policies were not followed, resulting in the presence of undated and expired food in storage areas.
Failure to Supervise Medication Administration Leads to Resident Self-Harm
Penalty
Summary
The facility failed to ensure the safety of a resident by not observing her take her medications, which led to the resident hiding and later ingesting multiple doses of Tylenol as an act of self-harm. The resident, who was cognitively intact with a BIMS score of 15, had a history of depression, anxiety, bipolar disorder, and other health issues. Despite her mental health conditions and the absence of an order for self-administration of medications, staff left her Tylenol on her bedside table without supervision, allowing her to accumulate and hide the medication in her room. The resident was later hospitalized for hypotension and liver failure, where she disclosed to hospital staff that she had ingested several Tylenol tablets in an attempt to end her life. Interviews with staff revealed that the resident had been isolating herself, refusing meals, and showing signs of severe depression. The Director of Nursing acknowledged that the staff had failed to supervise the resident adequately during medication administration, which was against the facility's policy that required staff to remain with residents until medications were swallowed.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The provider failed to adhere to their medication administration policy, resulting in a significant medication error involving a resident who required hospitalization. The resident, who was cognitively intact with a BIMS score of 15, had a history of depression, anxiety, bipolar disorder, and other medical conditions. Despite not having an order to self-administer medications, the resident was able to accumulate Tylenol tablets by hiding them in a plastic container in her dresser drawer. This occurred because the nursing staff left her medication on the bedside table and did not ensure she consumed it, contrary to the facility's policy that required staff to remain with residents until medications were swallowed. The incident came to light after the resident was hospitalized for hypotension and liver failure, following her admission that she had ingested several Tylenol tablets in a self-harm attempt. Interviews with staff revealed a lack of awareness and adherence to proper medication administration procedures, as well as insufficient education and monitoring following the incident. The director of nursing acknowledged the failure in staff oversight and the need for future audits, but no audits or monitoring had been conducted since the incident. The facility's policy clearly stated that medications should not be left with residents without orders and documentation for self-administration, which was not followed in this case.
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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