Sunset Manor Avera Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Irene, South Dakota.
- Location
- 129 E Clay St, Irene, South Dakota 57037
- CMS Provider Number
- 435100
- Inspections on file
- 26
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Sunset Manor Avera Health during CMS and state inspections, most recent first.
Staff initiated and continued CPR on a resident with a documented DNR/DNI order, failing to verify and honor the resident's code status before and during resuscitation efforts. Despite code status information being available in the EMR and on hall sheets, staff performed CPR for about 20 minutes until the DON intervened and stopped the procedure after confirming the DNR status.
A resident with a history of sexually inappropriate behavior was not properly supervised, resulting in unsolicited sexual contact with another resident in a common area. Despite care plans and staff instructions requiring 1:1 supervision within arm's length, staff failed to monitor the residents as required, and did not intervene during the incident. Afterward, there was no immediate assessment or investigation, contrary to facility policy.
A resident with dementia was subjected to unsolicited touching by another resident with a history of sexually inappropriate behavior while unmonitored in a hallway. Staff failed to provide immediate intervention and did not complete a timely assessment of the affected resident's physical and emotional well-being, despite facility policies requiring close supervision and prompt evaluation after such incidents.
A resident with a history of stroke and limited mobility was transferred using a sit-to-stand lift without the required safety straps, resulting in a fall to the floor. Staff and documentation confirmed that the safety straps were not used, and the care plan lacked clear instructions regarding transfer methods and fall risk. The manufacturer's instructions for the lift, which require the use of safety straps, were not followed.
A resident with severe cognitive impairment ingested a Santimine tablet due to improper storage in an unlocked drawer. The resident was on 1:1 monitoring but accessed the tablets when one CNA was assisting another resident. The drawer lock was broken, and the tablets were left unsecured by a CNA. This incident highlights a lapse in supervision and adherence to hazardous materials storage policy.
A resident with a traumatic brain injury (TBI) did not receive adequate dining assistance and nutritional care due to a lack of specific care planning and staff training. The resident, who required assistance with eating, missed several evening meals because he refused to leave his room and was not allowed meal trays in his room. The care plan lacked specific instructions, and documentation of meal intake was inconsistent. The facility's policy to maintain residents' well-being was not followed.
A significant deficiency was identified in a TBI unit where an LPN failed to provide necessary repositioning and toileting assistance to residents as per their care plans. The residents, who had severe cognitive impairments and complex medical conditions, were left in soiled clothing and bedding. The neglect was discovered through a complaint, video footage, and staff interviews, revealing inadequate training and communication among staff.
In a TBI unit, eight residents did not receive care as per their care plans, with one resident found in the same clothes, cold, and covered in feces. Video footage showed staff, including LPNs and CNAs, not providing necessary care, spending time at desks, and lacking an ADL policy, contributing to the deficiency.
A facility failed to accurately complete elopement risk evaluations for several residents, including one with dementia who eloped undetected due to a malfunctioning door alarm. Despite previous elopement incidents, the resident's risk was not updated in the care plan, and staff did not recognize the event as reportable.
A cognitively impaired resident was physically restrained by an agency CNA without medical necessity, following her return from the hospital. The restraint, which involved holding the resident's arms and pressing the CNA's chin into her scalp, was not documented and only discovered through video footage review. The incident occurred in the facility's challenging behavior unit, and other staff present did not report the abuse.
Failure to Honor Resident DNR Status During CPR
Penalty
Summary
Staff failed to follow a resident's documented Do Not Resuscitate (DNR) code status when the resident was found unresponsive with no pulse or respirations. Despite the presence of an advance directive and an active physician's order indicating DNR/DNI status, staff initiated and continued cardiopulmonary resuscitation (CPR) for approximately 20 minutes before the Director of Nursing (DON) arrived and instructed them to stop after verifying the resident's code status. The nurses involved reported that they began CPR, checked the code status, but continued resuscitation efforts under the belief that once CPR was started, it should not be stopped until emergency medical services arrived. The resident's code status was documented in both the electronic medical record (EMR) and on hall sheets that staff were expected to carry. Interviews revealed that while some staff understood the need to verify code status before initiating CPR, others did not follow this protocol during the incident. Additionally, a certified nursing assistant (CNA) reported that orientation training did not specifically address code status procedures, and the DON was unable to provide signed documentation verifying which staff attended a post-incident educational meeting on advance directives and code statuses. Facility policies required staff to provide basic life support, including CPR, unless a valid DNR order was in place, and indicated that code status information was accessible in the EMR and hall sheets. However, there was no evidence of ongoing auditing or monitoring to ensure staff awareness and adherence to these protocols at the time of the incident. The failure to verify and honor the resident's DNR status before and during resuscitation efforts constituted the deficiency.
Failure to Prevent and Respond to Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a known history of sexually inappropriate behavior was not adequately supervised, resulting in unsolicited sexual contact with another resident. The incident took place in a hallway and common areas where both residents, who ambulated independently via wheelchairs, were left unmonitored by staff. Despite care plan interventions and hall sheets indicating that both residents required 1:1 supervision within arm's length at all times, staff failed to maintain the required level of monitoring. Camera footage confirmed that staff, including a CNA and an LPN, were not present or did not intervene during multiple interactions, allowing the resident to touch the other resident's private area without consent. The resident who committed the inappropriate act had a documented history of dementia, altered mental status, anxiety, and previous sexually inappropriate behaviors, necessitating close supervision in common areas. The other resident had diagnoses including dementia, anxiety, psychotic disturbance, and mood disturbance, with significant communication limitations. Despite these known risks, staff did not follow the supervision protocols outlined in the care plans and staff meeting notes, which specifically required staff to be within arm's length of the resident with a history of inappropriate behavior. Additionally, after the incident, there was a lack of immediate assessment and documentation regarding the well-being of the resident who was touched. The LPN did not complete an assessment or incident report at the time, and the Director of Nursing did not initiate an internal investigation until several days after becoming aware of the incident. The facility's abuse prohibition policy required prompt reporting, assessment, and investigation of suspected abuse, but these procedures were not followed in this case.
Failure to Assess Resident After Unsolicited Physical Contact
Penalty
Summary
A deficiency occurred when staff failed to complete a resident assessment for the physical and emotional well-being of a resident who experienced unsolicited touching by another resident. The incident involved two residents, both with dementia and other cognitive impairments, who were independently ambulating in wheelchairs in a hallway unmonitored by staff. One resident approached the other, rubbed her leg, and later touched her private area without consent. Staff were not present to intervene during the initial incident, and when a CNA did encounter the residents, she did not immediately separate them or stop the inappropriate behavior. The nurse on duty was not aware of the proximity of the residents and did not witness the incident directly. Following the incident, the nurse did not conduct a timely assessment of the affected resident's physical or emotional state. Although the nurse documented a progress note based on secondhand reports from staff and housekeeping, she did not complete an incident report or perform an immediate assessment. The only assessment of the resident's vital signs occurred two days later, after the DON returned and inquired about the event. There was no documentation of a thorough evaluation of the resident's well-being or any follow-up notes addressing the incident's impact on her. The facility's policies required close monitoring of the resident with a history of sexually inappropriate behavior, including 1:1 supervision within arm's length in common areas. Documentation and staff meeting notes reiterated this requirement. However, video footage and staff interviews confirmed that this supervision was not maintained at the time of the incident. Additionally, the facility lacked a clear policy for incident reporting, relying instead on an electronic documentation system with dropdown options, which did not ensure that all necessary steps, such as resident assessment, were completed after such incidents.
Failure to Use Required Safety Straps During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was transferred using a sit-to-stand mechanical lift without the required safety straps, contrary to the manufacturer's instructions. The incident took place when the resident's right arm gave out during the transfer, causing the waist belt to pop off and resulting in the resident being lowered to the floor. The safety straps on the lift were not used on the resident's waist or legs during the transfer, and this omission was confirmed by both the facility's internal investigation and staff interviews. The resident initially refused medical treatment but later agreed to an x-ray, which showed no injury. The resident involved had a history of stroke resulting in no use of his left arm and leg, but was able to bear weight with a brace on his left leg. Documentation in the electronic medical record (EMR) indicated that the resident had previously refused to use the chest or leg straps during transfers, despite being educated on their necessity for safety. Staff interviews revealed that some staff had not experienced refusals from the resident, while others confirmed his refusals and described him as particular and sometimes verbally abusive regarding his care. The care plan and EMR lacked clear documentation about the resident's fall risk, transfer method, or history of falls. The facility relied on a working care plan and a hall sheet for daily care instructions, but the EMR care plan did not include specific transfer information. The manufacturer's instructions for the lift required the safety strap to be securely fastened around the patient's torso, and the use of a shin strap if necessary. The failure to follow these instructions and ensure the use of safety straps during the transfer directly led to the incident.
Resident Ingests Chemical Due to Improper Storage
Penalty
Summary
The deficiency involved a resident with severe cognitive impairment who ingested a Santimine tablet, a sanitizing chemical, due to improper storage. The resident, who had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment, was observed with a blue coloration in his mouth, which was identified as a Santimine tablet. The resident was on close 1:1 monitoring due to his cognitive condition and behavioral disturbances, yet he managed to access the tablets from an unlocked drawer in the Challenging Behaviors Unit (CBU). The incident occurred when two CNAs were present in the CBU, but one was assisting another resident in the bathroom, leaving the resident unsupervised momentarily. The Santimine tablets were supposed to be locked up, but they were found in an unlocked drawer behind resident clothing protectors. The drawer lock had been broken for some time, and the tablets were left unsecured by a CNA who had used them to make a cleaning solution earlier. This lapse in securing hazardous materials led to the resident's access to the tablets. Interviews with staff revealed that the Santimine tablets were not properly secured, and the staff were aware that they should have been locked. The facility's policy on hazardous materials required that such items be stored under lock and key to prevent access by residents. The failure to adhere to this policy and ensure the safety of the resident resulted in the ingestion incident, highlighting a significant lapse in supervision and storage of hazardous materials.
Failure to Provide Adequate Dining Assistance for TBI Resident
Penalty
Summary
The provider failed to ensure that dining assistance and nutritional needs were adequately care planned and implemented for a resident with a traumatic brain injury (TBI). The resident, who resided in the TBI unit, exhibited behavioral problems such as refusing care, medications, and meals. It was reported that if residents requiring assistance did not come out of their rooms, they were not allowed to have meal trays in their rooms. This led to the resident missing evening meals for three consecutive nights. Observations and interviews revealed that the resident was dependent on his spouse for eating assistance, and there was a lack of specific training for CNAs working in the TBI unit. The resident's care plan lacked specific instructions on the amount of eating assistance needed and did not indicate if he could eat in his room. The resident's electronic medical record showed inconsistent documentation of meal and snack intake, with several instances of the resident refusing evening meals without documented reasons or offers of alternative meals or snacks. The facility's policy required documentation of meals three times per day and as needed, but this was not consistently followed. The director of nursing confirmed that there was no specific training for CNAs in the TBI unit and that it was expected for staff to assist the resident with eating in his room if necessary. The facility's Resident Right-Nursing Home booklet emphasized the requirement to provide services to maintain the highest practicable well-being of each resident, which was not adhered to in this case.
Neglect of Residents in TBI Unit Due to Inadequate Care by LPN
Penalty
Summary
The report details a significant deficiency involving neglect of residents in a Traumatic Brain Injury (TBI) unit at a long-term care facility. Six out of eight sampled residents were not provided with necessary repositioning or toileting assistance as outlined in their care plans. The neglect was primarily attributed to a Licensed Practical Nurse (LPN) who failed to perform these duties during a night shift. The residents involved had severe cognitive impairments and required assistance with all activities of daily living, including toileting every two hours. However, the LPN did not provide the necessary care, leaving residents in soiled clothing and bedding. The deficiency was discovered following a complaint to the South Dakota Department of Health, which led to a review of video footage, interviews, and medical records. The footage revealed that the LPN spent significant periods at a desk rather than attending to the residents' needs. Interviews with staff indicated that the LPN was not adequately trained to perform Certified Nursing Assistant (CNA) tasks, and there was a lack of communication and coordination among staff regarding the care needs of the residents. The residents affected by this neglect had complex medical conditions, including traumatic brain injuries, dementia, and paralysis, which made them highly dependent on staff for their care. The failure to provide timely and appropriate care resulted in residents being left in uncomfortable and potentially harmful conditions, such as being cold, covered in feces, and soaked in urine. The facility's policies on neglect were not adhered to, as the staff did not provide the necessary goods and services to prevent physical harm and emotional distress to the residents.
Neglect in TBI Unit: Residents Not Provided Care as Directed
Penalty
Summary
The provider failed to ensure that eight residents in the Traumatic Brain Injury (TBI) unit received care as directed by their care plans. A complaint was filed with the South Dakota Department of Health, highlighting neglect in the TBI unit. Specifically, one resident was found in the same clothes from the previous day, curled up on the floor without a blanket, cold to the touch, and covered in feces. The resident's bed was untouched from the previous day. Other residents were noted to be incontinent of bowel and bladder, yet there was no evidence of care being provided to address these needs. The review of video footage from the TBI unit revealed that staff, including LPNs and CNAs, were present but did not provide the necessary care to the residents. The footage showed staff spending significant time at a desk or performing tasks unrelated to direct resident care. For example, one LPN was observed sitting at a desk for extended periods, and another staff member was seen entering and exiting rooms without providing care. The lack of an ADL policy and the absence of documented care activities further contributed to the deficiency, as staff failed to anticipate and meet the residents' needs, despite their cognitive impairments and dependency on staff for daily living activities.
Inaccurate Elopement Risk Evaluations
Penalty
Summary
The facility failed to ensure accurate elopement risk evaluations for 15 out of 22 residents, including a resident who had previously eloped. This resident, who had diagnoses of macular degeneration and dementia with behavioral disturbances, was able to leave the building undetected due to a malfunctioning door alarm. Despite having a Brief Interview for Mental Status (BIMS) score indicating moderate impairment, the resident's elopement risk evaluations were inaccurately marked as not at risk, even after a previous elopement incident. The facility's policy required elopement risk evaluations to be completed upon admission and after any elopement event, but this was not adhered to. Interviews with staff revealed that the elopement risk was not updated in the resident's care plan, and the incident was not initially recognized as an elopement or a reportable event. The facility's transition to a new electronic medical record system may have contributed to the oversight, as the resident's care plan and risk evaluations were not properly updated to reflect the elopement risk.
Resident Subjected to Unwarranted Physical Restraint by CNA
Penalty
Summary
The report details a deficiency involving a cognitively impaired resident who was subjected to physical restraint by an agency CNA, which was not required for medical treatment. The incident occurred after the resident returned from the hospital, where she had been treated for symptoms including slurred speech and weakness. Upon her return, the resident was restless and attempted to stand up multiple times, leading the CNA to physically restrain her by holding her arms down and pressing her chin into the resident's scalp. The incident was not immediately reported or documented in the resident's medical records, and it was only discovered after a review of video footage several days later. The footage showed the CNA restraining the resident for a total of 20 minutes over a 90-minute period. During this time, other staff members were present in the unit but did not witness or report the restraint. The facility's Director of Nursing and Administrator confirmed the occurrence of abuse after reviewing the footage. The resident involved had a history of unspecified dementia, bipolar disorder, and Alzheimer's disease, and was residing in the facility's challenging behavior unit. Despite the incident, the resident did not recall the event or any mistreatment by staff. The facility's policy prohibits the use of physical restraints unless necessary for medical symptoms, highlighting a failure in adherence to this policy in the reported incident.
Latest citations in South Dakota
Failure to Follow EBP and Hand Hygiene Practices: Staff did not wear gowns or gloves, did not perform hand hygiene, and did not clean an EZ stand lift after providing high-contact care to a resident on EBP with a Foley catheter. Staff also provided toileting care to a resident with open stage II pressure ulcers without gowns, and a housekeeper handled resident-room surfaces and items with unclean hands while cleaning rooms. Facility policy required gown and glove use for EBP, cleaning reusable equipment between residents, and hand hygiene after resident contact and glove removal.
A resident with severe cognitive impairment, TBI, and dementia with behavioral disturbances used a one-piece jumpsuit identified as a restraint intervention to address genital exposure and related behaviors. The EMR showed consent and physician approval, but the quarterly MDS and care documentation did not show whether the garment remained needed, whether less restrictive alternatives had been tried, or whether restraint reduction or elimination had been considered. Staff interviews confirmed the resident had not worn the garment in a long time, and the DON stated there was no restraint-specific documentation form to track its use or reassess the need for it.
Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
Failure to assess, document, and report new pressure ulcers: A resident with a pelvic fracture and intact cognition developed stage II pressure ulcers on both inner buttocks and a new pressure ulcer on the heel. Staff interviews and record review showed the DON/wound nurse did not document the heel wound or notify the MD, did not notify the MD when the left buttock ulcer was identified, and wound monitoring was not completed daily as required by the facility's own process.
Staff failed to follow a resident’s care-planned transfer needs. The resident had severely impaired cognition, a moderate fall risk score, and required dependent assistance with transfers, including a Hoyer lift with 2 staff or a sit-to-stand lift. Two CNAs lifted her by the underarms and pivoted her instead of using the ordered transfer method, and one CNA stated she did not use a gait belt because the resident was too tiny. The DON acknowledged the transfers were improper and unsafe because staff did not follow the care plan or Kardex.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Staff failed to honor several residents’ stated preferences regarding where they undressed for bathing, affecting their dignity and privacy. One resident reported that a CNA repeatedly undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his expressed wish to undress in the shower room. Other residents described similar experiences, stating that the CNA did not ask their preferences and routinely undressed them in their rooms before covering them with a sheet or blanket and taking them to the tub or shower room. Staff interviews confirmed that residents, particularly those requiring a mechanical lift, were typically undressed in their rooms and then transported covered, and the DON stated that facility protocol was to follow resident preference, consistent with the written dignity and privacy policy.
A resident reported that a contracted travel CNA placed hands down his pants while he was in bed, which he described as groping and not part of his usual care routine. Two RNs received this allegation; one counseled the CNA but did not notify leadership and did not know the required reporting time frame, while the other, who knew the 2‑hour reporting requirement, also failed to promptly inform the DON or administrator, delaying notification to state authorities and omitting contact with law enforcement and the ombudsman. In a separate incident, a resident’s family member reported suspected financial abuse to the social services designee, who informed the administrator, but the concern was not reported to the state agency or investigated as an abuse allegation; instead, the family was only given contact information for outside agencies. These actions did not follow the facility’s abuse policy requiring immediate internal reporting, prompt investigation, and timely reporting of all abuse and misappropriation allegations to the state agency.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
Failure to Follow EBP, Equipment Cleaning, and Hand Hygiene Practices
Penalty
Summary
Infection prevention and control practices were not followed during care for a resident on enhanced barrier precautions (EBP) who had a Foley catheter. During a transfer from a wheelchair to a recliner using an EZ stand lift, two CNAs/RMAs did not wear gowns or gloves, did not perform hand hygiene after the transfer, and one CNA/RMA placed the lift outside the resident’s room without cleaning it. One of the CNAs/RMAs stated she was expected to wear a gown and gloves for the transfer and remove them afterward, and the other stated she should have worn a gown and gloves and cleaned the lift after use. A second resident had open stage II pressure ulcers to both buttocks and a new pressure ulcer on the right heel, but was not placed on EBP. During observed toileting assistance, an RN and a CNA wore gloves but did not wear gowns while providing care to the resident’s open buttock wounds. The CNA applied barrier cream to the pressure ulcers and the rest of the buttocks. The RN stated the resident did not need EBP because the wounds did not have drainage, and the ADON/IP stated the resident was not on EBP because the pressure ulcer was not chronic. Housekeeping staff also did not follow hand hygiene practices while cleaning resident rooms. A housekeeper removed a mop head with bare hands, touched door handles without washing hands, and used unclean hands while moving between rooms and handling resident items and bathroom surfaces. The housekeeper stated she was supposed to wash her hands after cleaning a bathroom, after mopping, and between rooms, and the director of food and nutrition/housekeeping and housekeeping supervisor confirmed staff were to wash hands before and after glove use, after bathroom cleaning, and before and after mopping. Facility policy stated EBP required gown and glove use for high-contact care such as transferring and toileting, reusable equipment was to be cleaned and disinfected between residents, and hand hygiene was the primary means to prevent the spread of healthcare-associated infections.
Lack of Documentation for Ongoing Use of One-Piece Garment Restraint
Penalty
Summary
The provider failed to document whether one resident who used a one-piece jumpsuit as a restraint intervention was a candidate for restraint reduction, a less restrictive restraint method, or restraint elimination. The resident had severe cognitive impairment, a history of traumatic brain injury, and dementia with behavioral disturbances. He was observed seated in his wheelchair at breakfast and later in his recliner, repeatedly moving his feet, rocking his trunk, and placing his hand in and out of the waistband of his sweatpants. His EMR showed that the jumpsuit had been identified as a restraint intervention and that the resident's spouse had signed informed consent for its use. The record showed the resident had ongoing behaviors involving fondling himself and exposing his genitals, and staff requested physician approval for a one-piece garment to protect his dignity and prevent exposure to others. The physician approved the request. The quarterly MDS indicated the resident used a trunk restraint on a less-than-daily basis, and the MDS nurse's note stated that when available the resident would wear the one-piece jumpsuit. However, that assessment did not include documentation supporting continued use or discontinued use of the garment, and there was no indication that other alternatives had been tried. The behavioral tracking record documented other targeted behaviors, but fondling and exposing his genitals were not identified as targeted behaviors on that assessment. During interviews, an LPN stated the jumpsuit's zipper was on the backside of the garment, restricting the resident's access to his genitals, and said he had not worn it in a long time because of physical and cognitive decline. A CNA also stated she had not seen him wear the garment. The MDS nurse found the jumpsuit hanging in the resident's closet and acknowledged she did not know whether staff had completed restraint-related documentation. The DON stated there was no restraint-specific form to document when the jumpsuit was worn, what precipitated its use, what less restrictive interventions were tried, or how long it was worn, and acknowledged that without such documentation the quarterly assessment could not fully determine whether the jumpsuit remained needed or could be discontinued. The facility's restraint policy required least restrictive use, ongoing reevaluation, and quarterly review for restraint reduction, less restrictive methods, or elimination.
Failure to Follow Ordered Urology Consultation
Penalty
Summary
The nursing facility failed to follow a physician-ordered urology consultation for a resident with urinary retention and a Foley catheter. The resident had been hospitalized for a left femur fracture, and hospital records showed the Foley catheter was removed and later reinserted after a failed trial without catheter. After discharge to the skilled nursing facility, the physician was faxed about discontinuing the Foley catheter and responded to start Alfuzosin for 4 days and then attempt a trial without the catheter. When that trial failed, the physician ordered the Foley restarted and follow-up with urology. Subsequent physician progress notes in February, March, and April documented referral to urology for further evaluation and care, and the resident’s catheter care plan addressed Foley care but did not include a plan for removing the catheter. During interviews, an LPN stated she knew the resident was expected to be seen by a urologist but it had not yet occurred and she was not sure why. The DON and ADON/IP stated the physician was expected to call the urologist to make the referral and that the urology office would then confirm the appointment time. The ADON/IP recalled discussing the urology consultation with the physician during January rounds, but confirmed she did not discuss the status of the consultation during February, March, or April rounds and had no other discussions with the physician about it. The DON acknowledged the failure to follow the January physician-ordered urology consultation was 100% on the facility.
Failure to assess, document, and report new pressure ulcers
Penalty
Summary
The provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers for one resident who had returned to the facility from the hospital with a pelvic fracture and weakness and had an intact BIMS score of 15. The resident had a stage II pressure ulcer to the right inner buttock identified on 4/6/26, and later a stage II pressure ulcer to the left inner buttock was identified on 4/27/26. The record showed wound assessments on the right inner buttock, but the report states the wound assessment documentation was not completed weekly as required, and the physician was not notified when the left inner buttock ulcer was identified. The resident was observed sitting in a wheelchair on a Roho pressure-relief cushion and stated she had an open sore on her bottom. Staff interviews confirmed she had pressure ulcers on both inner buttocks, and a CNA reported finding a new pressure ulcer on the resident's right heel that was boggy and dark red and purple in color. An LPN stated the resident had stage II pressure ulcers to both inner buttocks and that the new right heel pressure ulcer had been found the previous day. The DON/wound nurse later stated she was not aware of the right heel pressure ulcer and could not find documentation of it or documentation that the physician had been notified. The record review showed the resident's wound assessments were completed on several dates for the right inner buttock ulcer, with measurements and descriptions documented, and the care plan addressed pressure ulcers to both inner buttocks. However, the DON/wound nurse stated nurses did not monitor pressure ulcers daily and that weekly skin assessments were the routine process. The provider's policy required nurses to document and report pressure ulcers, and the change-in-condition policy required physician notification within 24 hours for a significant change of condition. The DON/wound nurse stated she did not notify the physician when the left inner buttock ulcer was identified and planned to wait until the physician rounded at the facility later.
Unsafe Transfers Not Followed for a Resident With Care-Planned Lift Needs
Penalty
Summary
The nursing home failed to ensure safe transfers for resident 11, who had severely impaired cognition, a moderate fall risk score, and care-planned transfer needs requiring dependent staff assistance. Her revised care plan stated that she usually required a Hoyer lift with staff assist x 2 for transfers when she was not placing her feet on the ground for a pivot transfer with a gait belt and staff assist x 1-2, or a sit-to-stand lift. The resident was observed in the dining room being lifted by CNA F and CNA/RMA E, who each placed an arm beneath her underarms, raised her to standing, pivoted her, and lowered her into her wheelchair. CNA F later transferred the resident from the wheelchair to a recliner in the same manner and stated the resident could not bear her full weight and that she did not use a gait belt because the resident was too tiny. A separate observation showed CNA/RMA G using a sit-to-stand lift to transfer resident 11 from her wheelchair to the toilet and referring to the Kardex to confirm that a mechanical lift was required. The DON/wound nurse stated therapy assessed residents' mobility and transfer needs, those recommendations were added to the care plan, and the care plan information was then transferred to the Kardex so staff would know how to care for the resident. The DON acknowledged that CNA/RMA E and CNA F improperly and unsafely transferred resident 11 by failing to follow the transfer recommendations in the care plan and Kardex.
Failure to Maintain Safe Bed Systems and Prevent Accidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bed environment free from entrapment hazards and to provide adequate supervision and accident prevention for multiple residents. Surveyors observed that several residents had loose side rails or grab bars and mattresses that were not secured or properly fitted, creating gaps between the rails, mattress, and bedframe. One resident’s bilateral side rails could move away from the bed one to two inches, and there was a five‑inch gap between the top of his mattress and the headboard. Another resident, who was legally blind and had previously fallen out of bed during a dream and sustained a brain bleed, had a left side rail that could move three inches away from the mattress; he reported telling a CNA and his daughter about the loose rail about a week earlier. A third resident used bilateral side rails for bed mobility; her right rail could move two to three inches away from the bed, the openings within the rails measured three and one‑half inches wide by 13 inches high, and there was a seven‑inch gap between the foot of her mattress and the footboard. Surveyors also found that the facility’s entrapment assessments and maintenance audits were incomplete or inaccurately documented. Review of the maintenance logbook for side rail inspections from January through April showed that only zone 1 (the opening within the side rail) was consistently assessed, while the other six FDA‑defined entrapment zones were often marked as not applicable, including zone 7 (the space between the mattress and headboard or footboard) even for residents without bed rails. In some months, all seven zones were documented as not applicable for numerous residents known to have side rails, and some residents with side rails were not included in the audits at all. The DON was unsure if there was a specific entrapment assessment policy and believed maintenance handled these assessments, while also acknowledging missing documentation for side rail assessments, consents, and physician orders, and that some side rails were installed without proper documentation. Additional deficiencies related to accident prevention and supervision were identified in several facility‑reported incidents. One resident with a history of stroke and left‑sided weakness fell from his bed while trying to remove his socks after a CNA left his bed at waist height; his care plan at that time did not specify a required bed height, and he was later diagnosed with a minor closed head injury and abrasions. Another resident, care planned to require two staff for transfers and use of a sit‑to‑stand lift, was transferred by a single contracted CNA using a sling that was too small and the wrong hook, causing back pain; the resident and his family reported that he was often transferred by only one staff member despite the care plan. A cognitively impaired resident at risk for elopement exited through a door whose alarm had been deactivated during daytime hours so visitors could enter and exit, walked outside in very cold weather, and re‑entered through another door after about 15 minutes. A further resident, on anticoagulant therapy, fell while transferring herself to the bathroom and hit her head; she had fallen 11 times in 30 days, and the provider failed to implement, review, and revise interventions to reduce her fall risk. These events collectively demonstrate failures to follow care plans, maintain environmental safety devices such as alarms and bed systems, and provide adequate supervision to prevent accidents. The surveyors determined that these failures, particularly the unsecured side rails and unassessed mattress gaps, created a risk for entrapment injury or harm and issued an Immediate Jeopardy finding under F689 related to accident hazards and supervision. Observations throughout the building confirmed multiple safety concerns with side rail installation, maintenance, and bed zone assessments, including loose rails and significant gaps between mattresses and headboards or footboards. Facility leadership and maintenance staff acknowledged that gaps between mattresses and bed ends and loose side rails posed a risk for entrapment and injury, and that entrapment zone measurements and assessments had not been consistently completed according to FDA guidance and facility policy.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Failure to Honor Resident Bathing and Undressing Preferences
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity, respect, and self-determination regarding bathing and undressing practices. One resident reported in a facility reported incident that on his bath days, a CNA undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his stated preference to undress in the shower room. During a later interview, this resident stated that the CNA continued this practice, that it made him uncomfortable, and that it happened all the time. The DON stated that the bathing protocol was to follow each resident’s preference for where to undress, and that the CNA had been informed of this resident’s preference. The resident’s care plan documented his need for assistance with dressing but did not include his specific bathing or undressing location preferences. Additional interviews showed that this practice extended to other residents and was not individualized based on resident choice. The CNA acknowledged awareness of the resident’s preference but stated that all residents were undressed in the shower room, while another CNA described a typical routine in which residents with limited mobility who required a mechanical lift were undressed in their rooms, covered with a blanket, and then transported to the shower room. Another resident reported seeing the first resident transported to the shower room covered only by a blanket and stated that the CNA did not ask where he preferred to undress, instead beginning to undress him after announcing it was time for a bath. A third resident stated that the same CNA transferred him from bed to a chair, covered him with a white sheet, and took him to the tub room without asking his preferences, and that he had seen other residents transported in the same manner. These practices conflicted with the facility’s Resident Dignity & Privacy Policy, which required staff to groom and dress residents according to their preferences and to maintain privacy during care.
Failure to Timely Report and Investigate Allegations of Sexual and Financial Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and initiate required investigations into two separate allegations of abuse, including sexual and possible financial abuse. One resident reported that at approximately 6:00 a.m. a contracted travel CNA placed hands down his pants while he was in bed, allegedly to check if he was wet, which the resident described as groping that made him feel cheap. The resident stated he typically did not receive nighttime incontinence checks, as he used a urinal and was usually only awakened for early morning blood sugar checks or lab draws. He reported this incident to two RNs, one of whom acknowledged that it was not appropriate for staff to put their hands down a resident’s pants to check incontinence products. Despite this, the nurses who received the allegation did not immediately report it to the DON, administrator, or state agency as required by facility policy and federal guidelines. One RN spoke with the contracted travel CNA to “educate” her but did not notify anyone else and did not know the required reporting time frame. Another RN, who was aware of the process and the two-hour reporting requirement to the state health department, also failed to promptly report the allegation to the DON or administrator, resulting in a delay until late morning before leadership became aware. At the time leadership was notified, the allegation had not yet been investigated, and law enforcement and the ombudsman had not been contacted, even though the allegation involved possible sexual abuse. A second deficiency arose when a resident’s family member reported concerns of suspected financial abuse to the social services designee, who then informed the administrator. Instead of treating this as an abuse allegation requiring reporting and investigation under the facility’s abuse and neglect policy, the administrator did not report it to the state health department, citing a lack of detailed information. The social services designee and administrator only provided the family with contact information for external agencies such as the state’s attorney and adult protective services. The facility’s own policy required that all allegations and suspicions of abuse, including misappropriation of property and exploitation, be immediately reported to the administrator or designee, investigated by the administrator or designee, and reported to the state agency within two hours, but these procedures were not followed for either the sexual abuse allegation or the suspected financial abuse concern.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
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