Regional Health Care Center (SFF) Abuse and Neglect Attorneys

The Centers for Medicare and Medicaid Services (CMS) and the State of South Dakota conduct routine investigations, surveys, and inspections on every nursing home statewide. The surveyors and inspectors help to identify serious violations, health hazards, deficiencies that harm or could harm residents. In recent years, South Dakota personal lawyers have represented many victims of neglect, mistreatment or abuse occurring in nursing facilities throughout South Dakota.

In some cases, the violations are so serious that regulators will designate the nursing home as a Special Focus Facility (SFF). When this occurs, the federal government will place the facility on the Medicare deficiency watch list. In the months and years ahead, inspectors will conduct unscheduled surveys and unannounced visitations to investigate formally filed complaints.

Recently, regulators designated Regional Health Care Center as a Special Focus Facility. Some of the major concerns, serious health hazards, violations and deficiencies involving this facility are documented below.

Regional Health Care Center

This Nursing Center is a Medicaid/Medicare-participating 76-certified bed Facility providing services to the residents of Custer County, South Dakota. The ‘for profit’ Home is located at:

1065 Montgomery St.
Custer, SD 57730
(605) 673-2237
More Than $225,000 in Monetary Fines

When nursing home regulators identify a facility’s issues and problems to be out of compliance, they have the legal authority to impose monetary penalties. These fines alert the facility that provided substandard care is not tolerated.

Over the last 36 months, regulators have levied three monetary penalties against Regional Health Care Center. These penalties include an $11,150 fine on 06/01/2016, a $124,691 fine on 01/26/2017 and a fine of $112,520 on 04/12/2017. During that same time, regulators handled four formally filed complaints, and one facility-reported an issue that after investigations all resulted in citations.

Current Nursing Home Safety Concerns

Families can visit Medicare.gov to obtain a complete list of all filed complaints, health violations, opened investigations, safety concerns, incident inquiries, and dangerous hazards that are regularly updated by the state of Illinois and the federal government. This information can be used to make a well-informed decision of which nursing facilities in the community provide the highest level of care.

Currently, Regional Health Care Center maintains an overall two out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and four out of five stars for quality measures. Some serious deficiencies, violations, health hazards, and dangerous conditions involving this facility in the last few years include:

  • Failure to Develop a Comprehensive Care Plan That Resulted in the Resident’s Death
  • In a summary statement of deficiencies dated June 1, 2016, a formal complaint investigation against the facility was opened by a state investigator to identify failures and violations. The investigator noted the facility failed to “update and revise care plans for [one resident] that died after a fall.” The documentation revealed that the resident was admitted to the facility, had “six falls since his admission [and has since died].

    The state investigator reviewed the resident’s Care Plan that revealed a focus area related to falls. A goal with the target date […stating] ‘I have no serious injuries should I fall through the next review date.’” However, the investigator noted that “the Care Plan had not been updated or revised with the resident’s six falls.”

    A comprehensive investigation focused on the incidents involving another resident whose complete “medical record revealed” that she had “24 falls since admission and during the following months:

    • February – she had four falls,
    • March – she had eight falls,
    • April – she had four falls,
    • May – she had eight falls.”

    The investigator reviewed the resident’s Care Plan that stated that she “had a focus area of potential for falls. There are multiple fall interventions in place. Her Care Plan had not been updated with her falls .…a goal to have no-head injuries due to falls. An intervention for hipsters [non-skid socks] to be worn at all times.”

  • Failure to Report and Investigate Acts or Allegations of Abuse, Neglect or Mistreatment of Residents
  • In a summary statement of deficiencies dated February 9, 2017, a formal complaint investigation was opened against the facility by the state surveyor to identify failures and violations. The surveying team noted the facility’s failure to Ensure eight residents incidents “resulting in injury were thoroughly investigated and reported to the South Dakota Department of Health, per state and federal regulations.”

    One failure was identified in a resident’s Care Area Assessment Notes dated January 17, 2017, in the resident’s Minimum Data Set Assessment documenting the dementia patient is dependent on staff for cares, nourishment, positioning, falls or a potential.”

    Medical documents record an incident at 3:00 AM on January 27, 2017, when the resident “had a fall from her bed [and] became entrapped in a bed cane, metal repositioning bar attached to the bed frame), and receive the large skin tear to her upper right arm.” The resident was “sent to the emergency room for evaluation.” The following week on February 6, 2017, at 2:03 PM, the resident “was noted to have an injury to her left great toenail, it was loose and bleeding. There was no indication of what had caused the injury.”

  • Failure to Provide Care and Services That Meet Professional Standards of Quality [recurring deficiency]
  • In a summary statement of deficiencies dated June 1, 2016, a formal complaint investigation was opened against the facility by a state investigator to identify violations and failures. The investigator documented that the facility had “failed to ensure complete, accurate, and professional documentation had been recorded for [two residents] who had choked.”

    One incident was documented in a resident’s Progress Notes by a Registered Nurse that revealed the resident “started choking after eating in the cafeteria.” The Registered Nurse “and an Aide did the Heimlich [maneuver and were] unable to remove what she was choking on.” The resident passed away because of the incident.”

    A review of the Progress Note – Incorrect Documentation Progress Note revealed that “at about 12:30 today, [the resident] was in the cafeteria having lunch. I was at the Nurses’ Station charting and doing charge duties when an Aide came out and said she needed a nurse quick. So, I ran to the cafeteria, had two individuals stand her up, and I did three thrusts of the Heimlich [maneuver and then the Certified Nursing Assistant (CNA)] did three thrusts, and then I said ‘quick, let’s get her to oxygen and suction.’ We took her in the wheelchair to a room that the crash cart was in, but it was not there, and so we started to wheel her to her room, and she fell our of the wheelchair and was mottled.”

    The Registered Nurse stated that “I heard no air exchange, [so] we picked her up and took her to her room and I was asking [the Certified Nursing Assistant] to give me some suctioning and oxygen, but the crash cart was not in full operation.’” During this time, in [the resident’s room, the CNA] had her on the floor doing abdominal thrusts. We confirmed in her chart she was ‘no CPR and no life-saving measures.’ I asked [the Certified Nursing Assistant] to stop. She had no apical pulse [and] no air exchange.”

    In a separate summary statement of deficiencies dated April 12, 2017, a state investigator opened the complaint investigation against the facility to identify failures. The state team noted the facility’s failure “to ensure parameters were in place for notifying a physician of low blood glucose results for [one resident] with abnormal glucose readings.” Additional deficiencies also included a failure to “monitor and document accurate fluid intakes for [one resident] with the physician’s orders,” and a failure to “ensure a nurse assessed one [resident] for pain [before] a medication aide medicating with as-needed [PRN] pain medication.”

    The investigator also stated the facility failed to “clean a nebulizer medication chamber and mouthpiece according to the provider’s policy after receiving nebulizer medication for [three residents].” An additional deficiency included a failure to “follow the provider’s policy regarding neurological (neuro) checks after a fall [for one resident].”

  • Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores
  • In a summary statement of deficiencies dated December 18, 2014, a state survey team opened the complaint investigation against the facility to identify failures and violations. The team determined that the facility “failed to ensure seven [residents] had not acquired an avoidable pressure ulcer or skin tears after admission to the facility as evidenced by ineffective care planning process and skin/wound preventative program.”

  • Failure to Provide Residents an Environment Free of Accident Hazards [recurring deficiency]
  • In a summary statement of deficiencies dated December 18, 2014, the state investigator documented the facility’s failure to “ensure for a four-door’s (front, maintenance/delivery, ambulance/staff, and multi-purpose room) routinely used by staff and visitors were alarmed at all times.” Additional problems identified as safety hazards were listed as deficiencies including:

    • Two arms of the EZ lift in Hall 2 were not maintained to prevent possible skin tears and punctures;
    • One of the whirlpool rooms (in the Hall 3 secured unit) was not locked;
    • Thirteen residents did not have care plans, assessments, or education to nursing staff or grab or positioning bars on their beds;
    • Four safety trend reports did not appropriately address the evidence and data regarding the high numbers of falls and skin incidents for residents.

    In a separate summary statement of deficiencies dated April 12, 2017, the state investigator documented the facility’s failure to “ensure two randomly observed mechanical transfer lifts located on [the 100 and 200 hallways] had safety tabs present per manufacturer guidelines.” The state investigator observed both EZ Way Stand Mechanical Lifts on two separate hallways that had “no safety tabs attached to the harness attachment area.” The safety tabs are required to ensure that the “transfer slings remain in place while transferring residents from one location to another. The residents would not have fallen from the mechanical lift.”

  • Failure to Follow Protocols and Procedures to Prevent the Spread of Infection throughout the Facility [recurring deficiency]
  • In a summary statement of deficiencies dated December 18, 2014, a state survey team opened the complaint investigation against the facility to identify violations and failures. The state investigator documented the facility’s failure to “identify necessity and implement appropriate contact isolation precautions. Educate, train, and monitor all staff including housekeeping and laundry regarding the appropriate use of personal protective equipment, handwashing, and hygiene, in the handling of soiled equipment, laundry, and trash.

    The investigator also documented the facility’s failure to “ensure all management and administration had been aware of all the ill residents on Hall 3. There was also a documented failure to “ensure timely notification about reportable diseases [to be] made to the Office of Disease Prevention.”

    In a separate summary statement of deficiencies dated April 12, 2017, a formal complaint investigation was opened against the facility by a state surveyor to identify failures. The staff determined that the facility had failed to “ensure appropriate handwashing and gloving was used during dressing changes for [three residents].” Surveyors identified an additional deficiency involving a failure of “personal cares for [three residents].” Additionally, an observation of the whirlpool tub cleaning was inaccurately disinfected according to the provider’s policy.

  • Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores
  • In a summary statement of deficiencies dated April 12, 2017, a complaint investigation against the facility was opened to identify failures and violations. The state survey team documented the facility had failed to “ensure [five residents] identified at risk for skin breakdown had received appropriate care and service to prevent new pressure injury from occurring or prevent current pressure injury from worsening.”

  • Failure to Provide Care for Residents in a Way That Keeps or Builds Each Resident’s Dignity and Respect of Individuality
  • In a summary statement of deficiencies dated December 18, 2014, the state surveying agency opened a formal complaint investigation against the nursing home to identify failures. The investigator found the facility failed “to maintain residents’ rights according to three [residents].

    One incident was revealed in an interview that occurred at 4:40 PM on December 17, 2014, when the resident said “she did not use her call light most of the time. It did not help to get staff to assist her any faster. She would use it for her roommate.” The resident stated that “she could not wait fifteen or more minutes for help to arrive because she would soil herself. She stated the Certified Nursing Assistants [CNA] would snap at her at times when she needed help. She could not remember [the names of the CNAs], but they still worked there.”

    Another resident stated that stated they were no longer able “to watch her preferred television programs. That had been one of her primary activity she had enjoyed.” A third resident “had not been offered activities of her choice or activity she had enjoyed.”

    The state investigator conducted a resident group interview on the afternoon of December 16, 2014. The resident’s “voice preference to not being identified individual and can armed call lights were good when they were good. But when they were bad, they were bad. He stated it was hard to sit and wait twenty minutes or more when he had used the bathroom.” The resident’s “confirmed that happened more at night and in the early morning.”

Was Your Loved One Abuse or Neglected in a Nursing Home?

Was your loved one abused, neglected, or mistreated while a resident at Regional Health Care Center, or any convalescent Center? If so, hiring an attorney to represent your compensation claim could be beneficial. A lawyer working on behalf of your family can ensure all the necessary documentation is filed in the appropriate South Dakota courthouse before the state statute of limitations expires. The law firm will gather evidence, build a case, present evidence at court, or negotiate an acceptable help of court settlement to recover your damages.

You will not be required to make any upfront payment to receive immediate legal services. The fees are postponed until after your lawyers have successfully resolved your nursing home abuse case and obtained your funds through a jury trial award or settlement.

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Client Reviews
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Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
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After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric