Four Seasons Health Care Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Forman, North Dakota.
- Location
- 483 4th St Sw, Forman, North Dakota 58032
- CMS Provider Number
- 355103
- Inspections on file
- 22
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Four Seasons Health Care Inc during CMS and state inspections, most recent first.
Staff failed to assess and utilize the correct sling sizes for two residents during full body mechanical lift transfers, resulting in the use of slings without proper size identification or the use of an incorrect size. Staff relied on a general sizing chart in the supply room rather than individualized assessments, and there was no documentation or education provided regarding appropriate sling selection.
A resident with severe cognitive impairment was subjected to repeated unwanted sexual contact by another resident, also with severe cognitive impairment, despite staff interventions after the initial incident. The inappropriate contact occurred multiple times in a monitored lounge area before one-to-one supervision was implemented, in violation of the facility's abuse prevention policy.
A resident with COPD, pulmonary fibrosis, and CHF experienced a decline in condition, with low oxygen saturation levels and difficulty breathing. The facility failed to document nurse progress notes for several days and did not promptly assess or notify a physician of the resident's condition changes. The resident expressed distress and was eventually transferred to the ER, where he passed away shortly after arrival.
The facility failed to develop an effective QAPI process, resulting in continued noncompliance with federal regulations. Deficiencies were identified in areas such as Bed Hold Policy, Care Plan Timing, Quality of Care, Accident Hazards, Food Sanitation, and Infection Control. Despite having a policy for performance improvement, the facility did not maintain compliance, as evidenced by deficiencies cited during surveys.
The facility failed to ensure a safe, clean, and homelike environment in multiple areas, including the supply room, laundry room, oxygen storage room, and resident rooms. Observations revealed dust on an oxygen concentrator, debris in the laundry room, and damaged walls and furniture in resident rooms. Staff interviews confirmed a lack of processes for identifying areas needing cleaning or repairs.
The facility failed to accurately code the MDS for several residents, including the presence of an indwelling catheter, insulin use, and antiplatelet medication. These inaccuracies were confirmed by an administrative nurse and could affect the development of comprehensive care plans.
The facility failed to provide sufficient nursing staff, resulting in delays in care for three residents. A resident reported waiting 20-30 minutes for toileting assistance at night, while another had to wait for two staff members to assist, leading to prolonged periods in a wet pad and soreness. A third resident experienced 1-2 hour delays in receiving pain cream for knee pain across all shifts. These issues highlight inadequate staffing, particularly during the overnight shift.
The facility failed to adhere to food storage and sanitation standards, with a metal scoop improperly stored in a flour bin, an unlabeled shaker in a cooler, and expired sanitizer test strips affecting concentration results. Additionally, dried substances were found in a resident refrigerator, indicating a lack of cleanliness.
A facility failed to provide a timely written bed hold notice to a resident or their representative during a hospital transfer. The policy requires the notice to be given before transfer or within 24 hours in emergencies. However, the notice was delayed by eight days, as confirmed by an administrative staff member.
A facility failed to complete a PASARR for a resident newly diagnosed with delusions and hallucinations. Despite communication with a physician and an increase in antipsychotic medication, the facility did not update the Level I screen as required, leading to a deficiency in compliance with regulatory procedures.
The facility failed to update care plans for three residents, impacting staff communication and care continuity. A resident's care plan was not revised after a foley catheter removal, while two residents' care plans contained outdated medication information, referencing incorrect anticoagulant treatments.
A nurse failed to administer Voltaren gel according to physician orders, applying an undetermined amount directly from the tube to a resident's arms and shoulders without measuring the correct dosage. The facility's policy requires medications to be administered as ordered and in accordance with professional standards, which was not followed in this instance.
A facility failed to use a gait belt during a resident's transfer, risking falls and injury, despite the resident's history of repeated falls and a care plan requiring assistance. Additionally, a resident with dementia ingested craft paint due to an unlocked supply cabinet, leading to an ER visit. The facility's policy required such materials to be secured.
The facility failed to ensure medications were securely stored and properly dated, with a treatment cart left unlocked and unattended, and expired medications found in the medication room. An administrative staff member expected staff to lock the treatment cart when unattended.
A facility failed to follow its infection control policy during wound care for a resident. The policy requires gowns and gloves for high-contact activities to prevent the spread of multidrug-resistant organisms. A nurse changed a resident's abdominal wound dressing wearing only gloves, without a gown, and the room lacked EBP signage. The facility also did not obtain an order for enhanced barrier precautions for the resident, who required daily dressing changes.
The facility did not post accurate and complete staffing information for three days during a survey. Observations showed that the daily staffing reports were not updated as required by facility policy. An administrative staff member noted that the charge nurse was responsible for posting the daily staffing report.
Failure to Assess and Use Correct Sling Size During Mechanical Lift Transfers
Penalty
Summary
The facility failed to utilize appropriate assistive devices necessary to prevent accidents and/or injury for two residents observed during mechanical lift transfers. Specifically, staff did not assess or use the correct sling sizes for residents requiring full body mechanical lift transfers. For one resident, the sling used during transfer did not have a size noted, and for another, staff could not locate the resident's usual sling and instead used a large-sized sling without confirming its appropriateness. Staff interviews revealed that sling size information was only available on a chart in the supply room, and there was no individualized assessment or documentation of correct sling size for each resident. Further review and interviews confirmed that the facility had not assessed residents who require full body mechanical lifts for the appropriate sling size, nor had they provided staff with adequate information or education regarding proper sling selection. The lack of assessment and failure to ensure the use of correct sling sizes during transfers placed residents at risk for falls and injuries, as observed during the survey.
Failure to Prevent Repeated Sexual Abuse Between Residents with Dementia
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from repeated unwanted sexual contact by another resident, also with severe cognitive impairment. On the day of the incident, a staff member observed one resident with his face in the breast area of another resident in the lounge. When questioned, the resident stated he was just talking to her. The affected resident was removed to a safer location near the nurse's station, and the other resident was redirected to his room and counseled. Despite these interventions, the same resident was observed again shortly after kissing the affected resident on the mouth in the lounge, and later, touching her inappropriately. The affected resident was noted to have wandering behaviors and frequently entered the lounge area, which was monitored by the facility's camera system. The inappropriate sexual contact occurred three times within a short period before the facility implemented one-to-one supervision for the resident exhibiting the sexual behaviors. Both residents had diagnoses of dementia and were identified as having severe cognitive impairment on their Minimum Data Set assessments. The facility's policy stated that all residents have the right to be free from abuse, including sexual abuse, and that residents must not be subjected to abuse by anyone, including other residents. However, the facility did not prevent the repeated incidents of nonconsensual sexual contact before taking more intensive supervisory action.
Failure to Provide Timely Care and Intervention
Penalty
Summary
The facility failed to provide necessary care and services for a resident with chronic obstructive pulmonary disease, pulmonary fibrosis, and congestive heart failure. The resident's medical record lacked documentation of nurse progress notes for three consecutive days, and there was a failure to assess, monitor, and implement interventions in response to the resident's declining condition. On one occasion, the resident's oxygen saturation was recorded at 81% while on three liters of oxygen, yet there was no documented assessment, treatment intervention, or physician notification. Later, the resident's oxygen saturation improved slightly to 89%, but again, no further action was documented. The resident expressed feeling unwell and reported difficulty breathing, stating he was dying and unable to eat. Despite these significant changes in condition, there was a delay in notifying the physician, with a gap of several hours between the resident's report of distress and the facility's contact with the physician's clinic. The resident was eventually transferred to the emergency room, where he passed away shortly after arrival. The lack of timely intervention and communication with the physician contributed to the resident's decline and subsequent death.
Facility's Ineffective QAPI Process Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to develop an effective Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services and outcomes. This failure was identified through a review of the facility's QAPI program, policies, survey findings, and staff interviews. The facility's policy, dated 10/02/24, outlined a systematic approach to performance improvement, including data analysis, corrective action, and performance tracking. However, the facility did not maintain compliance with federal requirements, as evidenced by deficiencies cited during the last standard survey and a subsequent Federal Monitoring Survey. The deficiencies included issues related to the Notice of Bed Hold Policy, Care Plan Timing and Revision, Quality of Care, Accident Hazards/Supervision/Devices, Food Procurement and Sanitation, and Infection Prevention and Control. Despite the facility's policy stating that the Quality Assessment and Assurance (QAA) Committee would continue to collect and analyze data to ensure improvements, the facility failed to effectively utilize its Quality Assurance processes. This resulted in continued noncompliance with federal regulations, as indicated by the deficiencies cited under F625, F657, F684, F689, F812, and F880.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several areas, including the supply room, laundry room, oxygen storage room, and resident rooms. Observations during the survey revealed an oxygen concentrator with dust on the outside and filter, and oxygen tubing and a mask were found on the floor beside the machine. Additionally, a portable liquid oxygen tank and a nebulizer machine were also placed on the floor next to the concentrator. In the laundry room, there was visible dust and debris on a fan grate and blades, which were blowing into the clean laundry area. The oxygen storage room had two ceiling vents with a thick layer of dust, cracked and broken floor tiles, a visible layer of fine dirt along the floor perimeter, and ceiling tiles with water leak marks. In the resident rooms, Unit A had scuff marks, chipped paint, and gouges on the walls. Room B8 had an overbed table with a two-inch strip of missing laminate along the front length, exposing the wood, and a large area of loose laminate on the right top side. The top of the oxygen concentrator in room B8 was also covered in dust. During interviews, a maintenance staff member confirmed the lack of a process for identifying areas needing cleaning or repairs and was unaware of any resident room concerns. An administrative staff member stated that staff were expected to clean and sanitize oxygen and nebulizer equipment before storage and dispose of items like oxygen tubing and masks in the resident's room.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for eight residents, which is crucial for reflecting each resident's current status and needs. Specifically, the facility did not accurately code the presence of an indwelling catheter for one resident, as the MDS indicated its presence despite observations and medical records showing otherwise. Additionally, the facility failed to code insulin use for another resident who had physician orders for insulin glargine to manage diabetes mellitus type 2. Furthermore, the facility did not code the use of antiplatelet medication, specifically aspirin, for six residents on their respective MDS assessments. These omissions were confirmed by an administrative nurse during interviews, highlighting a pattern of inaccurate MDS coding across multiple residents. This inaccuracy in MDS coding could potentially impact the development of comprehensive care plans and the care provided to the residents.
Insufficient Nursing Staff Leads to Delays in Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, as evidenced by confidential interviews with three residents. Resident A reported a consistent wait time of 20-30 minutes for toileting clean-up assistance during the night shift, which had been ongoing since their admission several weeks prior. Resident B expressed that the facility was understaffed, requiring two staff members for assistance, resulting in prolonged periods of sitting in a wet pad and developing soreness. This issue was particularly noted after evening care and throughout the night. Resident C experienced delays of 1-2 hours in receiving pain cream for knee pain, with these delays occurring across all shifts. These findings indicate a failure to provide adequate staffing to meet the residents' needs, particularly during the overnight shift.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards in both the kitchen and a resident refrigerator. During a kitchen tour, a metal scoop was found improperly stored inside a flour bin, contrary to the facility's policy that requires scoops to be kept outside storage bins in protective containers. Additionally, an unlabeled and undated shaker containing milk and oatmeal was found in a reach-in cooler, which was identified as belonging to a staff member. This lack of labeling and dating contravenes the facility's policy on food safety, which mandates that all food brought into the facility be labeled and dated. Furthermore, the facility did not ensure the proper concentration of sanitizer solution used for cleaning resident dining room tables. An unidentified dietary staff member tested the sanitizer concentration and found it to be out-of-range, with the test strips used being expired. This could potentially affect the effectiveness of the sanitizer. Additionally, dried liquid substances were observed on two shelves inside a refrigerator located in the main lobby, which is used to store foods brought in by family members. The dietary manager confirmed the expectations for food storage and acknowledged the expired test strips, which may have affected the sanitizer test results.
Failure to Provide Timely Bed Hold Notice
Penalty
Summary
The facility failed to provide a timely written bed hold notice to a resident or their representative during a hospital transfer. According to the facility's policy, a written notice detailing the bed hold policy should be provided before a resident is transferred to the hospital, or within 24 hours in the case of an emergency transfer. However, for one resident who was transferred to the hospital, the facility delayed providing this notice until eight days after the transfer. This delay was confirmed by an administrative staff member during an interview, indicating a lapse in adhering to the facility's policy and regulatory requirements.
Failure to Complete PASARR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a status change assessment for a resident who was newly diagnosed with mental illness, specifically delusions and hallucinations. According to the North Dakota PASARR Provider Manual, a change in status process must be initiated when a significant change in a resident's mental health status occurs. This includes contacting the contracted agency to update the Level I screen and determine if a Level II evaluation is necessary. The resident's medical record indicated that a PASARR was completed in August 2021, but subsequent progress notes in September 2024 documented communication with a physician regarding the resident's delusions and hallucinations, leading to an increase in antipsychotic medication. However, there was no evidence that the facility staff completed a PASARR related to these new diagnoses. During an interview, a social services staff member confirmed that the facility did not complete a change in status Level I screen for the resident. This oversight could result in the delivery of care and services that do not align with the resident's current needs, as the facility did not follow the required procedures for updating the resident's mental health status. The lack of a completed PASARR assessment following the emergence of new mental health conditions represents a deficiency in the facility's compliance with regulatory requirements.
Failure to Update Care Plans Following Medical Changes
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of three residents, which limited the staff's ability to communicate needs and ensure continuity of care. For Resident #4, the care plan was not updated to reflect the removal of a foley catheter, as confirmed by an administrative nurse during an interview. Despite the absence of an indwelling catheter observed on 10/28/24, the care plan still indicated its presence. For Resident #10, the care plan inaccurately referenced monitoring for bleeding problems due to Plavix use, despite a physician's order for Eliquis, an anticoagulant medication. Similarly, Resident #23's care plan was not updated after the discontinuation of warfarin on 05/01/24, as it still included instructions for PT/INR checks and Coumadin dose adjustments. These discrepancies highlight the facility's failure to update care plans following significant changes in residents' medical treatments.
Failure to Administer Topical Medication as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of topical medication for a resident. During a medication pass, a nurse was observed applying Voltaren gel to a resident's arms and shoulders without measuring the correct dosage as specified in the physician's orders. The orders required the application of 2 grams of Voltaren gel to the shoulders and 4 grams to the knees, but the nurse dispensed an undetermined amount directly from the tube into a gloved hand, failing to use the dosing card as per the manufacturer's specifications. The deficiency was confirmed through observation, record review, and staff interviews. The facility's medication administration policy mandates that medications be administered as ordered by the physician and in accordance with professional standards. The administrative staff acknowledged that the nurse did not follow the provider's orders for accurately measuring and applying the medication, which could potentially lead to adverse outcomes for the resident.
Failure to Utilize Gait Belt and Secure Hazardous Materials
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for a resident during a gait belt transfer. A licensed nurse assisted the resident to stand up from a sitting position by placing her arm under the resident's arm, failing to utilize a gait belt during the transfer. The resident's medical record indicated repeated falls, and the care plan required staff assistance with transfer and locomotion. This failure to use a gait belt placed the resident at risk for falls and/or injury. Additionally, the facility failed to ensure the safety of a resident who ingested non-toxic craft paint. The resident, who had diagnoses of dementia, restlessness, agitation, and wandering, was found with craft paint on his arms, mouth, and pants. The nurse was unsure of how much paint the resident might have consumed, and the resident was sent to the ER for evaluation. The facility's incident report noted that the cabinet containing the paint was unlocked, despite staff being aware that it should always be locked to prevent access by residents with altered mental status.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly dated, expired medications were discarded, and medications were securely stored in two of three storage areas, specifically the treatment cart and medication room. During an observation, a staff nurse left a treatment cart unlocked and unattended for approximately 20 minutes while entering a resident's room. During this time, residents and staff walked past the unlocked cart, and one resident stood next to it without the nurse present. This lack of security could lead to unauthorized access to medications. Additionally, an observation of the medication room revealed that a locked refrigerator contained expired medications and an undated multi-dose vial. Specifically, three acetaminophen suppositories had expired on 12/31/23, and an opened, undated multi-dose vial of tubersol was found. An administrative staff member stated that she expected staff to lock the treatment cart when it was unattended or out of sight, indicating a failure to adhere to facility policies regarding medication storage and security.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy during wound care for a resident. The policy, titled Enhanced Barrier Precautions (EBP), requires the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multidrug-resistant organisms. During the survey, it was observed that a staff nurse entered the resident's room, which lacked EBP signage, and proceeded to change the resident's abdominal wound dressing while only wearing gloves, neglecting to wear a gown as mandated by the facility's policy. Additionally, the facility staff did not obtain an order for enhanced barrier precautions for the resident, who had a wound on the right abdomen requiring daily dressing changes as per the physician's order.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to ensure the posting of accurate and complete staffing information on three out of four days during the survey period from October 27 to October 29, 2024. This deficiency was identified through observation, review of facility policy, and staff interviews. The facility's policy requires the posting of daily staffing information for each shift, detailing the number of licensed and unlicensed staff responsible for resident care. However, observations revealed that the facility did not update the staffing reports on the clipboard located by the nurse's station during the specified days. An administrative staff member indicated that the charge nurse was expected to complete and post the daily census/staffing report.
Latest citations in North Dakota
A resident with dementia, restlessness, agitation, and a documented history of entering others’ rooms, rummaging, and exhibiting verbal and physical behaviors was involved in multiple abusive encounters with other residents. In separate incidents, this resident hit another resident in a TV lounge after handling that resident’s bag, punched a resident on the chin/cheek while following behind with a walker, grabbed another resident’s arm near the TV leading to mutual hitting and a fall onto a recliner occupied by a third resident, kicked a resident while being escorted to dinner, and lifted a resident’s chair cushion while searching for a wallet, leading to a profane verbal exchange. Several of the involved residents had impaired cognition, while others had intact cognition but histories of mood and behavioral issues. Staff interviews showed limited description of immediate protective actions when witnessing resident-to-resident aggression, and an administrator noted that the aggressive resident had not been evaluated by psychiatry for an extended period. The facility failed to prevent repeated verbal and physical abuse among residents, resulting in retaliatory abuse toward the aggressive resident.
Two residents did not receive care that maintained their dignity during grooming and personal hygiene. One resident had noticeable facial hair and reported preferring to be shaved with an electric razor, but stated that only a straight razor was available, despite facility policy and administrative statements that grooming should follow resident preference and that shaving materials are provided. Another resident was transferred to bed by a nurse and a CNA, given perineal care, and placed in a clean brief, but staff left the resident’s pants down and simply covered the resident with a blanket, contrary to administrative expectations that pants be pulled up or removed in bed according to resident preference.
A resident with Parkinson’s disease, muscle weakness, unsteadiness on feet, and gait/mobility abnormalities had a care plan requiring a stand-pivot transfer with two staff and a gait belt. During an observed toileting transfer, two CNAs assisted the resident, who showed visible shakiness and an unsteady gait, but one CNA placed her hands around the resident’s ribcage to move the resident back to the wheelchair instead of using a gait belt as required. The CNA later acknowledged not using a gait belt, and administrative staff confirmed their expectation that gait belts be used during transfers per the care plan.
Staff failed to follow infection prevention and control policies when handling reusable equipment and soiled linens for two residents, including one on enhanced barrier precautions (EBP). A CNA removed a full body mechanical lift from a resident’s room without disinfecting it, despite facility expectations for cleaning after each use. In a separate incident, CNAs entered the room of a resident on EBP wearing only gloves initially, and one CNA placed soiled linens on the floor instead of directly into a bag, even after donning a gown. An RN later confirmed that staff were expected to disinfect lifts after every use, avoid placing soiled linen on the floor, and wear gowns upon entering EBP rooms.
The facility failed to prevent resident-to-resident physical abuse when a cognitively impaired resident with dementia-related behavioral issues, already care planned for aggressive mood fluctuations and a history of physical contact, grabbed and forcefully squeezed another resident’s arm in a hallway and, in a separate episode, yelled and struck another cognitively impaired resident in the face multiple times while they were seated together. In both incidents, the affected residents, who had dementia and other psychiatric diagnoses, reported or were documented as having been physically assaulted, though no injuries were ultimately noted, demonstrating that residents were not kept free from abuse by another resident as required by facility policy.
The facility failed to investigate two separate resident-on-resident altercations involving a cognitively impaired resident with dementia, anxiety, and a care plan noting aggressive mood fluctuations and prior physical contact with others. In the first incident, this resident grabbed and forcefully squeezed another resident’s arm in a hallway after being tapped on the shoulder, but the facility did not complete the interviews and root cause analysis required by its abuse policy. In the second incident, the same resident began yelling, swinging, and striking another resident in the face multiple times while they were sitting and talking; although the assaulted resident had no noted injuries and the aggressor was moved to a quiet area, there is no evidence of a thorough abuse investigation or evaluation of interventions after the initial event.
A resident with Parkinson’s disease and Alzheimer’s disease, who was non-verbal, non-ambulatory, and unable to self-transfer, had a care plan requiring substantial assistance by two staff and use of a sit-to-stand lift for transfers after 5 p.m. Facility policy also required use of mechanical lifts as a safer alternative and mandated two staff for mechanical lift transfers. Despite these requirements, a CNA did not follow the care plan during a transfer, and the resident was later found with a head lump, facial and hand lacerations, and blood on the floor. An investigation concluded the injuries likely occurred during or shortly after this improper transfer, in which the required lift and two-person assistance were not used.
A resident with a breast lump had ongoing right breast hardness and later worsening scabbed, reddened, and draining changes, but the record lacked evidence of provider assessment or a mammogram order before the resident was sent to the ER and hospitalized for breast infection and possible cancer. Another resident with dysphagia was ordered nectar thick liquids via straw, but staff offered liquids in a glass and later a sipper cup instead, and the resident immediately coughed after each attempt; the care plan still listed sipper cups with spouts.
Failure to maintain resident dignity and provide timely assistance: staff used residents’ clothing protectors and a spoon to wipe food from residents’ mouths during meals instead of a napkin, left one resident calling out for help in the room for an extended period, and did not adequately supervise or assist two residents who needed meal cueing, encouragement, or help. One resident with stroke-related weakness, mild cognitive impairment, and dysphagia struggled to self-feed with adaptive utensils out of reach, while another resident with dysphagia was left with a barely eaten meal and repeated requests for help.
Medication administration errors exceeded the allowed rate when an LPN made four errors during 27 observed med passes, resulting in a 14% error rate. Errors included crushing finasteride ordered not to be crushed, giving levothyroxine with food instead of on an empty stomach, and priming insulin pens at the wrong angle for two residents. Facility policy and staff interview confirmed the correct administration requirements.
Failure to Prevent Repeated Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from verbal and physical abuse by another resident with known behavioral issues. Facility policies on resident-to-resident altercations and abuse/neglect defined verbally aggressive behaviors such as screaming and cursing, and physically aggressive behaviors such as hitting, kicking, grabbing, pushing, and rummaging through others’ property, and affirmed residents’ right to be free from verbal, physical, and mental abuse. Resident #1 had documented diagnoses including dementia, restlessness, and agitation, with a care plan noting a history of entering other residents’ rooms, rummaging, and exhibiting verbal and physical behaviors. Despite this, Resident #1 was involved in multiple altercations with other residents over a short period. In one incident with Resident #3, video and investigation documentation showed Resident #3 sitting in a recliner in a common TV area while Resident #1 was near other recliners. Resident #3 told Resident #1 to leave electrical cords alone, then got up and approached Resident #1. Resident #1 began to handle Resident #3’s bag on the recliner, after which Resident #3 hit Resident #1 on the left side of the head, and Resident #1 hit Resident #3 on the left arm. Resident #3 had a history of depression, anxiety, mental disorder, mild cognitive disorder, and prior verbal and physical behaviors, with an MDS indicating intact cognition. In another incident with Resident #4, video review and notes showed Resident #4 ambulating with a walker past the nurse’s station into the TV area, followed closely by Resident #1. Resident #1 was seen standing directly behind Resident #4, appearing to make a comment; Resident #4 swatted at Resident #1, and Resident #1 then struck Resident #4 on the left chin/cheek area. A progress note documented that Resident #1 punched Resident #4 when Resident #4 did not respond to Resident #1’s attempt to engage in conversation. Additional altercations involved Resident #2, #5, and #6. In the incident with Resident #2, video review showed Resident #1 standing in front of the TV fidgeting with the control box, then later walking over to Resident #2 and grabbing her arm as if to guide her away from the TV. Resident #2 responded by hitting Resident #1’s left arm, and Resident #1 hit her back on the right arm; both then grabbed each other, fell onto a recliner occupied by another resident, and staff intervened. Resident #2’s MDS indicated severely impaired cognition, and she sustained transient red marks on her head and upper inner arm. In another event, the activity director was walking residents to dinner when Resident #1 kicked Resident #5, who was walking in front, and then chuckled; Resident #5, who also had severely impaired cognition, recalled being kicked and stated the other resident was “not 100 percent.” In a separate episode with Resident #6, staff heard Resident #6 yelling profanities at Resident #1, who was lifting her chair cushion looking for his wallet; Resident #1 raised his voice and called her an explicit name, and Resident #6 prepared to remove her shoe to use toward him before staff intervened. Resident #6, with intact cognition, later stated that Resident #1 wanted to hurt her and that he had hit her friend (Resident #4) for no reason. Staff interviews further illustrated gaps in protecting residents from abuse. One staff member, when asked what she would do if she witnessed a resident hit another resident, stated she would get the RNs and “try to get a hold of someone,” without describing immediate protective interventions. An administrative staff member reported that Resident #1 had not been seen by psychiatry since 2024, despite his documented dementia with psychotic disturbances and ongoing behavioral issues. Across these events, the facility did not prevent repeated verbal and physical altercations initiated or escalated by Resident #1 toward other residents, which led to retaliatory physical and verbal abuse by those residents toward Resident #1.
Failure to Maintain Resident Dignity During Grooming and Personal Care
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents who required assistance with personal hygiene and care. Facility policy on promoting/maintaining resident dignity stated that residents should be groomed and dressed according to their preferences, and the grooming policy specified assisting residents with facial hair care to maintain proper hygiene. During observation, one resident was noted to have noticeable facial hair and, in an interview, stated a preference to have facial hair shaved with an electric razor; the resident reported that the facility only had a straight razor available. An administrative staff member stated that all residents are shaved per their preferences and that shaving materials are provided, which conflicted with the resident’s report. In a separate observation, a nurse and a CNA transferred another resident from a wheelchair to a bed, completed perineal care, applied a clean brief, and then covered the resident with a blanket without pulling up the resident’s pants. Later, an administrative staff member stated that she expected staff to either pull up or remove residents’ pants in bed according to resident preference, indicating that the observed practice did not align with facility expectations or policies regarding resident dignity and grooming.
Failure to Use Gait Belt During Stand-Pivot Transfer
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to follow its Safe Resident Handling/Transfers policy and the resident’s care plan requiring use of a gait belt during transfers. The facility policy stated that residents are to be handled and transferred safely to prevent or minimize risk for injury and that lifting and transferring will be performed according to the resident’s individual plan of care. Resident #2’s medical record showed diagnoses of Parkinson’s disease, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. The resident’s current care plan specified a stand-pivot transfer with two staff assisting and the use of a gait belt. During an observation, two CNAs wheeled Resident #2 to the toilet, where the resident used grab bars to transfer from the wheelchair to the toilet, exhibiting visible shakiness and an unsteady gait. After toileting, one CNA cued the resident to stand, applied a clean brief and pants, then placed her hands around the resident’s ribcage to assist the resident back to the wheelchair instead of using a gait belt as required by the care plan. The CNA later confirmed in an interview that a gait belt was not used during toileting care. In a separate interview, three administrative staff members stated they expected staff to utilize a gait belt during transfers as care planned.
Failure to Follow Infection Control Practices for Equipment Cleaning and EBP
Penalty
Summary
Surveyors identified that staff did not follow the facility’s infection prevention and control policies related to cleaning reusable equipment, handling soiled linen, and implementing enhanced barrier precautions (EBP). The facility’s policies required that reusable equipment be cleaned and disinfected according to current procedures and manufacturer’s instructions after each resident use, and that EBP involve targeted gown and glove use during high-contact resident care activities. During observation, a CNA removed a full body mechanical lift from a resident’s room and failed to disinfect it, while stating that lifts and wheelchairs were cleaned by the night shift, contrary to the facility’s expectation that the lift be disinfected after every use. Surveyors also observed failures in infection control practices for a resident on EBP. Two CNAs entered the resident’s room and initially only applied gloves. One CNA placed soiled linen from the floor into a bag, and after being instructed by a nurse to apply PPE, the CNA then donned a gown but removed soiled linen from the bed and again placed it on the floor. The nurse stated that soiled linens should be placed directly into a bag and not on the floor. An administrative staff member later confirmed that staff were expected to disinfect full body mechanical lifts after every use, avoid placing soiled linen on the floor, and wear gowns when entering rooms requiring EBP precautions.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. Facility policy on abuse, neglect, mistreatment, and misappropriation of resident property, dated 07/07/21, states that all residents have the right to be free from verbal, sexual, and physical abuse and must not be subject to abuse by anyone, including other residents. Despite this policy, one resident with Alzheimer's disease, restlessness and agitation, anxiety disorder, and severely impaired cognition, who had a care plan noting aggressive mood fluctuations related to dementia and anxiety and a history of physical contact with another resident, physically grabbed, pulled, and squeezed another resident's arm in a hallway incident. The resident whose arm was grabbed had non-Alzheimer's dementia, anxiety disorder, depression, and intact cognition, and later reported that the aggressor was strong and that she had to pull her arm away, though she stated she was not hurt. In a separate incident, the same cognitively impaired resident with dementia-related behavioral issues struck another resident multiple times in the face while they were sitting next to each other and talking. The progress note documented that the aggressor began yelling and swinging, hitting the other resident in the face multiple times. The resident who was hit, who had dementia, anxiety, behavior disturbance, psychotic disorder, and severely impaired cognition, reported at the time that the other resident “just started hitting me in the face” and that she moved away, and no injuries or pain were noted on assessment. Both involved residents in this second incident were described as confused and unable to be interviewed for the facility’s FRI investigation. The facility’s failure to prevent these two episodes of resident-to-resident physical abuse, despite known behavioral risks and a care plan addressing aggressive behavior, resulted in residents not remaining free from abuse as required by facility policy.
Failure to Investigate Resident-on-Resident Abuse Incidents
Penalty
Summary
The facility failed to investigate alleged violations of abuse involving two residents who were physically assaulted by another resident with a known history of aggressive mood fluctuations related to dementia and anxiety. Facility policy on Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property required that the nurse begin an investigation immediately, including root cause analysis and interviews with staff, roommates, family, and visitors. An FRI dated 01/25/26 documented an incident in which one resident grabbed, pulled, and squeezed another resident’s arm in the west hallway. The final investigation note only reflected that the resident whose arm was grabbed reported that the aggressor was strong but that her arm was okay, and later described that she had tapped the aggressor on the shoulder to compliment her sweater, after which the aggressor grabbed her arm hard and she had to pull away. There is no documentation in the report of a comprehensive investigation consistent with facility policy. A second FRI dated 02/02/26 documented that the same aggressive resident began yelling, swinging, and hitting another resident in the face multiple times while they were sitting together and talking. The assaulted resident stated that the aggressor “just started hitting me in the face, so I moved away from her” and suggested the aggressor “needs a shot or something.” Assessment at that time showed no injuries and no pain, and the aggressor was moved to a quiet area. Medical records showed the aggressor had Alzheimer’s disease, restlessness and agitation, anxiety disorder, severely impaired cognition, and a care plan noting aggressive mood fluctuations and a history of physical contact with another resident, with an intervention to maintain distance from others when appropriate for safety. The other involved residents had dementia and anxiety disorders, with one having intact cognition and the other severely impaired cognition. Although both incidents were reported to facility administration and the state agency, the facility did not conduct investigations of the altercations in accordance with its policy, nor did it implement and evaluate appropriate interventions following the first incident.
Improper Transfer Without Required Lift and Staff Assistance
Penalty
Summary
The deficiency involves the facility’s failure to properly utilize required assistive devices and staff assistance during a resident transfer, contrary to its Safe Resident Handling/Transfers With Use of Mechanical Lifts policy. The policy required that mechanical lifts be used as a safer alternative when appropriate and that two staff members be utilized when transferring residents with a mechanical lift. The care plan for Resident #1, who had diagnoses including Parkinson’s disease and Alzheimer’s disease and could not self-transfer, specified that the resident required substantial assistance by two staff to move between surfaces from morning until evening, and that after 5 p.m. transfers were to be completed using a sit-to-stand lift with assistance from two staff. On the date of the incident, Resident #1’s progress notes documented that the resident, who was non-verbal and non-ambulatory, was found with a significant lump on the right forehead, a small laceration above the right eye, and a laceration on the right hand, with a small amount of blood on the floor. The resident was unable to undergo a complete neurological assessment due to their condition and was sent to the ER for further evaluation. The facility’s incident investigation concluded that the injuries likely occurred during or shortly after an improper transfer and that a CNA failed to follow the resident’s care plan requiring use of a sit-to-stand lift with two staff, resulting in the unsafe transfer and subsequent injuries.
Failure to Follow Up on Breast Lump and Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for a resident with an identified breast lump. The resident’s record showed a breast lump was identified on 10/19/24, and the facility notified the provider on 10/21/24 after the resident agreed to a mammogram. From October 2024 through June 2025, nursing notes continued to document a hard lump on the right breast, but the record lacked evidence that the provider assessed the lump or ordered a mammogram. Later progress notes documented worsening findings of the right breast area, including a scab below the right areola, hardness around the areola, minimal discharge, erythema, increased size, purulent exudate, and a larger reddened and hardened area with tenderness. On 08/06/25, the resident was sent to the ER for evaluation after no improvement in the right breast region. The facility later documented that the resident was admitted to the hospital for infection and possible breast cancer, received IV antibiotics for breast infection, and that a CT scan showed the underlying breast tissue was cancerous. The facility also failed to ensure safe oral intake for a resident with dysphagia who required nectar thick liquids via straw. The resident had diagnoses including cerebrovascular disease, dementia, oropharyngeal dysphagia, and reflux disease, and the speech therapy evaluation identified coughing with thin liquids and ordered a mechanically altered diet with nectar thick liquids via straw sip. The care plan still included sipper cups with spouts, and observations showed staff offering nectar thick liquids in a glass and later in a sipper cup rather than via a straw; each time the resident immediately coughed. Staff also observed that water in the room had not been thickened before it was offered.
Failure to Maintain Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained and respected resident dignity during meals for two sampled residents and two supplemental residents. During dining observations, a CNA fed two residents and used their clothing protectors to wipe excess food from the corners of their mouths, and a nurse used a small coated spoon to remove excess food from one resident’s mouth. On another meal observation, a CNA again used a resident’s clothing protector to wipe food from the resident’s mouth, and the nurse repeated the use of a small coated spoon to remove food from the resident’s mouth. Administrative staff confirmed staff should use a napkin to remove excess food from a resident’s face. The facility also failed to respond in a timely manner to a resident who requested assistance in the room. The resident’s care plan stated the resident needed prompt response to all requests for assistance, could make self understood, and should be encouraged to use the call bell. During observation, the resident’s room door was closed and the resident repeatedly hollered for staff assistance for 37 minutes until the surveyor summoned help. In addition, two residents who required meal supervision, cueing, encouragement, and/or assistance were observed at lunch with inadequate staff support: one resident with hemiplegia, hemiparesis, mild cognitive impairment, dysphagia, and a history of stroke had adaptive silverware out of reach and was left to attempt self-feeding, spilling juice and dropping food into the lap, while another resident with dysphagia was observed drinking from a coffee cup, repeatedly saying, 'Take this,' with the meal barely eaten and no effective cueing or assistance provided.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent for 3 of 6 residents observed during medication administration. During observation of 27 medications administered by nurse #7, four medication errors occurred, resulting in a 14 percent error rate. The report states that failure to follow physician's orders and/or pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. For Resident #12, the medical record showed orders for finasteride 5 mg with directions not to crush or split, and levothyroxine 50 mcg. During observation, nurse #7 crushed the finasteride and placed it, along with the levothyroxine and other medications, in strawberry ice cream for administration. For Residents #3 and #77, nurse #7 primed their insulin pens at a 45-degree angle. Facility policy and reference information reviewed by surveyors stated that finasteride should not be crushed, levothyroxine should be given on an empty stomach, and insulin pens should be primed with the needle pointing upward at a 90-degree angle. Administrative staff confirmed these administration expectations during interview.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
