Good Samaritan Society - Larimore
Inspection history, citations, penalties and survey trends for this long-term care facility in Larimore, North Dakota.
- Location
- 501 E Front St, Larimore, North Dakota 58251
- CMS Provider Number
- 355097
- Inspections on file
- 26
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Good Samaritan Society - Larimore during CMS and state inspections, most recent first.
Code status documentation was missing or incomplete for 4 sampled residents. Review of records and the facility’s ACP policy showed CPR/full code orders for several residents, but the chart often lacked proof that the resident or legal representative agreed with the order; for one resident, the signed consent was only produced during the survey. A management staff member confirmed staff failed to obtain signed documentation of the resident/resident representative’s wishes regarding code status.
Cold meal trays were served to residents in a parlor area after delays in tray delivery and service. Residents stated their breakfast items were not warm or were cold, and surveyors confirmed the food was cold during a taste test. Staff later noted that trays should be served immediately and that temperatures are checked when there is concern about late service or delivery.
Failure to provide needed grooming and bathing assistance affected several residents. A few residents were observed with overgrown hair and stated they needed haircuts, while staff reported the facility had not had a beautician for some time. Another resident with extensive assist needs for bathing and personal hygiene was observed with long hair, an untrimmed beard, and food in the beard, and bathing records showed a long gap between baths without documentation of refusal or rescheduling.
Failure to inform residents of psychotropic medication risks and benefits. Three sampled residents had orders for antidepressants, including Zoloft, Trazodone, and Cymbalta, but their records lacked evidence that they or their representatives were informed about the risks and benefits of these medications. An administrative nurse confirmed the missing documentation.
Failure to maintain privacy during personal care was observed for a resident during toileting. Staff were noted in council minutes to knock but not always wait for a response, and during observation two staff members and a CNA entered the resident's room and bathroom without waiting for acknowledgment while the resident was on the toilet.
The facility failed to accurately code the MDS for two residents. One resident had diagnoses of bipolar disorder and major depression, but the annual MDS did not code PASRR or serious mental illness items in Section A. Another resident was taking Metformin and Gabapentin, but the quarterly MDS did not code the hypoglycemic or anticonvulsant medication items in Section N. An administrative staff member confirmed the coding errors.
Failure to use safe transfer devices occurred when staff assisted a resident with weakness and unsteady legs during transfers without consistently using the required gait belt. A CNA pulled on the gait belt and the back of the resident’s pants during pivot transfers, and later an RN assisted the resident to stand without a gait belt, using a 4-wheeled rolling walker that rolled away as the resident sat back on the bed.
Failure to maintain ordered oxygen occurred when a CNA removed a resident’s nasal cannula during toileting and transfer assistance, leaving the resident without oxygen for 26 minutes. The resident appeared short of breath, and when the nurse assessed the resident, the oxygen saturation was 82% before the cannula was reapplied and the saturation improved to 92% to 94%.
Failure to post accurate nurse staffing information was identified when staffing postings displayed only prior weekday data and were not updated for the weekend. An LPN confirmed the staffing information had not been updated for Saturday and Sunday.
Medication administration errors resulted in an 8% error rate, exceeding the facility’s limit of less than 5%. An LPN gave a resident’s levothyroxine with other morning meds shortly before breakfast instead of on an empty stomach before breakfast, and applied another resident’s lidocaine patch contrary to the provider’s order for bedtime application and morning removal. The nurse confirmed both errors during interview.
Unsecured medication cart and mismatched pantoprazole orders: A medication cart was observed unlocked and unattended in a hallway, with the eMAR visible to staff and residents. During med pass, two residents' pantoprazole labels did not match the eMAR/provider orders, and a staff nurse confirmed the discrepancy.
Failure to monitor freezer temperatures and follow safe storage practices was identified for 1 of 3 freezer units. Facility policy required freezer temperatures to be 0 degrees Fahrenheit or lower and recorded twice daily, but there was no documentation for the parlor area freezer for several months. When observed, the freezer temperature was 6 degrees Fahrenheit, and the remaining food was removed and discarded. An admin staff member stated the expected temperature was 0 degrees Fahrenheit or below.
The facility failed to ensure the QAPI group included all required members at least quarterly. Review of QAPI sign-in sheets showed the medical director had not attended any meetings since August 2025, and an administrative staff member confirmed the MD did not attend the required quarterly QAPI committee meetings.
Infection control practices were not followed for two residents. A CNA assisted a resident on EBP with toileting without wearing a gown during high-contact care, and an RN administered medications to another resident without performing hand hygiene before glove use, after removing gloves, or before exiting the room.
A resident with anxiety, depression, and a prior stroke had a history of sexually inappropriate behaviors toward staff and other residents. Although the chart included a psych referral, increased antidepressant dose, and notes about sending referrals for placement, the facility did not document the basis for the transfer/discharge, did not revise the discharge plan, and did not consistently document an ongoing safety threat requiring immediate discharge.
Failure to notify a resident's representative of an ER transfer was identified for one resident. Facility policy required written notice of transfer or discharge and the reason for the move, and the transfer checklist directed staff to notify family or guardian and document the notification. The resident's record showed a hospital transfer, but no written transfer notice was provided, and an admin staff member confirmed the representative was not notified.
Two residents with pressure ulcers did not receive consistent repositioning or timely application of protective devices as ordered, and staff failed to document these interventions. One resident's care plan was not updated to include a repositioning schedule for nearly a month after deep tissue injuries were identified, and there were significant delays in coordinating wound care referrals, resulting in deterioration of wounds and hospitalization.
Staff did not use a gait belt while assisting a resident with a transfer from a wheelchair to a recliner, despite the resident's documented need for assistance due to weakness. During the transfer, the resident's knees gave out, resulting in a fall in which the resident struck her head and sustained a right hip fracture. The facility's policy required gait belt use during transfers, but this was not followed, leading to the incident.
The facility did not ensure that the person acting as dietary manager had completed the required education or held a national certification for food service management and safety. The dietary manager was still enrolled in a certification course and had not yet finished it.
The facility did not establish or utilize an effective QAPI process to identify and address deficiencies in care planning, incontinence management, nursing staffing, medication errors, and food service sanitation. Audits were conducted, but there was a lack of monitoring in the specific areas cited, leading to ongoing noncompliance.
The facility did not employ a staff member with specialized training in infection prevention and control to oversee the Infection Prevention and Control program, as confirmed by policy review and staff interviews.
Care plans for four residents were not updated to reflect current physician orders and resident needs, including missing documentation for blood sugar monitoring, oxygen requirements, pain management, edema interventions, and accurate fluid restrictions. These deficiencies limited staff communication and continuity of care.
Multiple residents and family members reported long wait times for call light responses, delays in toileting assistance, and inadequate hygiene support due to insufficient CNA staffing. Staffing records confirmed that the facility did not consistently provide the necessary number of CNAs or a bath aide on several days, resulting in unmet resident needs and delays in care.
The facility did not consistently provide or distribute snacks to residents according to their needs and preferences. Residents reported that snacks were often left at the nurse's station and not delivered to rooms, with one diabetic resident noting the impact on their care. Observations showed snacks being left unattended and touched by residents, and staff confirmed that snack delivery was not their responsibility.
Surveyors found improper food storage practices, including food boxes placed directly on an iced freezer floor, personal items such as medication and cola stored in the kitchen refrigerator, and large bundles of flowers kept in the walk-in refrigerator. These actions violated facility policy and professional standards, as confirmed by administrative staff.
A resident with severe cognitive impairment repeatedly engaged in inappropriate sexual behaviors towards female residents, including touching and making advances, despite existing care plan interventions. Staff intervened during incidents and documented them, but the facility did not recognize these actions as sexual abuse or update interventions to prevent recurrence. The affected residents included individuals with dementia and memory issues.
A resident with severe cognitive impairment was involved in multiple incidents of inappropriate sexual contact with another resident. Although staff intervened and documented the events, the facility did not report these incidents of resident-to-resident sexual abuse to the State Survey Agency as required by policy.
Surveyors found that the facility did not accurately code the MDS for three residents, including failing to document a diagnosis related to an indwelling catheter for a resident with BPH and not coding antiplatelet medication use for two residents taking daily aspirin. These omissions were confirmed by staff interviews.
A newly admitted resident with diabetes and hydrocephalus did not have an accurate baseline care plan developed, as the plan misidentified medication purposes, failed to address insulin use and blood sugar interventions, and omitted necessary interventions for hydrocephalus. Administrative staff confirmed the care plan did not reflect the resident's actual clinical needs.
A resident who was permitted to smoke independently was repeatedly found smoking in unauthorized indoor and entryway areas, despite staff instructions and facility policy requiring use of a designated outdoor area. Surveyors also observed that cigarettes and lighters were stored in an unlocked box with the key left in place, and staff interviews revealed inconsistent understanding and enforcement of smoking material security procedures.
Two residents requiring staff assistance with toileting and incontinence care did not receive scheduled checks, changes, or appropriate interventions as outlined in their care plans. Staff failed to consistently check briefs, encourage toileting, provide education, or notify nursing staff of refusals, resulting in prolonged periods without care and inadequate documentation of refusals.
A resident receiving hemodialysis for chronic kidney disease did not have documentation of communication from the dialysis unit regarding their condition during and after treatments. Staff confirmed that while necessary documents were sent with the resident, no handoff information was received from the dialysis facility, resulting in a failure to monitor and document the resident's post-dialysis status as required by facility policy.
Surveyors observed that staff failed to follow proper medication administration procedures, including crushing medications that should not be crushed and incorrectly priming insulin pens, resulting in a medication error rate of fifteen percent. Errors included a medication aide crushing delayed-release and extended-release tablets before administration to a resident, and a nurse priming insulin pens incorrectly for two residents.
The facility did not post accurate daily nurse staffing information, as the forms displayed in a common area did not correctly reflect the number of unlicensed staff on duty for each shift. Both administrative and scheduling staff confirmed the inaccuracies during the survey.
Code Status Documentation Missing for Multiple Residents
Penalty
Summary
The facility failed to ensure residents’ rights to request, refuse, and/or discontinue treatment were honored for 4 of 14 sampled residents reviewed for advance directives and code status. Review of the facility’s Advanced Care Planning policy showed that advance directive discussions must be documented in the medical record and that advance directive orders are to be reviewed with the resident or healthcare decision-maker at each care plan meeting. The deficiency involved Resident #7, Resident #10, Resident #24, and Resident #25, whose records were reviewed during the survey. Resident #7, Resident #24, and Resident #25 each had physician orders indicating CPR/full code status, but their records lacked documentation showing that the resident or representative agreed with the code status. For Resident #10, the record also showed a physician order for CPR, and when surveyors asked for documentation of agreement with the code status, the facility produced a document signed by the resident during the survey. During an interview, a management staff member confirmed staff failed to obtain signed documentation regarding the resident or resident representative’s wishes about code status.
Cold Meal Trays Served After Delayed Delivery
Penalty
Summary
The facility failed to serve foods at a palatable temperature for one tray-cart service in the parlor area. The facility policy titled Room-Tray Service-Food and Nutrition, revised March 2025, stated that room/tray service should be periodically monitored to ensure quality, timeliness, and compliance with food temperature standards. During observation, a cart containing food trays was seen in the parlor area while residents were eating. One resident was served a breakfast tray of eggs and toast and stated the food was not warm, while another resident later stated his eggs were cold. On another observation, covered room trays were placed in the meal tray cart and delivered to the parlor area; a nursing staff member served the first tray and the last tray about 30 minutes later, and a taste test by surveyors confirmed the food items were cold. On a later observation, trays were again placed in the cart for delivery, and when a delay was noted, a dietary staff member was asked to check temperatures, returned the cart to the kitchen, and stated the kitchen staff would prepare warm food for the residents. An administrative staff member stated the expectation was that CNAs serve the trays immediately and that staff check food temperatures when there is concern with late service or delivery.
Failure to Provide Needed Grooming and Bathing Assistance
Penalty
Summary
The facility failed to ensure residents received the necessary services to maintain good grooming for Residents #2, #3, #36, and supplemental Resident #33. Observation and interview findings showed Resident #3 had long hair and stated it had been a long time since a beautician had provided a haircut. Resident #2 was observed with hair over the tops of both ears and stated, "I could use a cut. It's been a while." Resident #33 was observed with hair over the tops of both ears and bangs covering much of the left side of the face, and stated, "I could use a cut." An administrative staff member stated a beautician had not been in the facility since 12/22/25 and the facility currently did not have one. Resident Council meeting minutes also reflected residents asking whether there would be a new beauty operator. For Resident #36, the care plan identified extensive assistance of one staff member for bathing and personal hygiene, yet observation showed long hair, a beard with thick hair growth on the neck, and food in the lower beard along the lip line. A CNA assisted with toileting but did not offer help to clean the resident's face. The bathing schedule showed Resident #36 was to receive a bath on Wednesdays, but bathing documentation showed a whirlpool bath on 03/04/26 and again on 03/18/26, leaving 13 days without a bath. The record did not show that the resident refused a bath or that the missed bath was rescheduled, and staff stated that if a bath is not completed on the scheduled day, the charge nurse should discuss an alternate day with the resident and document the conversation.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform 3 of 5 sampled residents, Resident #2, Resident #7, and Resident #17, or their representatives about the risks and benefits related to psychotropic medications. Resident #2 had a physician order dated 02/04/26 for Zoloft daily, Resident #7 had a physician order dated 03/25/25 for Trazodone at bedtime, and Resident #17 had a physician order dated 02/22/25 for Cymbalta daily. For each of these residents, the medical record lacked evidence that the resident or representative was informed of the risks and benefits associated with the use of the psychotropic medication. During an interview on the afternoon of 03/17/2026, an administrative nurse confirmed that the records for Resident #2, Resident #7, and Resident #17 did not document that the residents or their representatives received this information.
Failure to Maintain Privacy During Toileting Care
Penalty
Summary
The facility failed to provide privacy and ensure dignity during personal cares for one sampled resident, Resident #25, during toileting care. Resident Council meeting minutes noted that staff should knock on the door and wait for a response, but that staff were knocking and coming right in, including in the tub room, and sometimes did not wait long enough for a response. During observation on 03/15/26 at 2:04 p.m., a CNA transferred Resident #25 from a wheelchair to the toilet for toileting cares. On two occasions, unidentified staff members knocked on the resident's room door, immediately opened the door, and began to enter the room, then closed the door and left when they saw the surveyor. Later, a CNA knocked on the resident's room door, immediately entered the room, and walked into the bathroom. After noticing Resident #25 on the toilet, the CNA backed out, knocked on the bathroom door, stated, "I just need to check something," reentered the bathroom, and reached for a container on a shelf above the toilet. The staff members failed to wait for acknowledgment from the CNA or Resident #25 before entering the room and bathroom.
MDS Coding Errors for Mental Illness and Medications
Penalty
Summary
The facility failed to ensure accurate coding of the MDS for 2 of 14 sampled residents. For Resident #2, record review identified diagnoses of bipolar disorder and major depression since 2018, but the annual MDS did not code Section A1500 for PASRR or Section A1510 for serious mental illness. The RAI User's Manual stated that PASRR Level II screening should be coded when it determines a resident has a serious mental illness, and Section A1510 should be coded for serious mental illness when the resident has been diagnosed with one. For Resident #3, record review showed current medications of Metformin twice daily and Gabapentin four times daily. The quarterly MDS did not code Section N0415J1 for hypoglycemic medication or Section N0415K1 for anticonvulsant medication, even though the RAI User's Manual stated these items should be checked if the resident took those medications at any time during the 7-day observation period. During interview, an administrative staff member confirmed the facility failed to correctly code Section A for Resident #2 and Section N for Resident #3.
Failure to Use Safe Transfer Devices
Penalty
Summary
The facility failed to utilize assistive devices necessary to ensure safe transfers for one resident who did not walk due to safety concerns and required partial to moderate staff assistance with transfers. The resident’s care plan identified assistance of one staff member for transfers, toilet use, and personal hygiene related to weakness. The facility policy titled Gait-Transfer Belt stated that a gait transfer belt is used to safely stabilize a transfer and aid residents in maintaining balance, and that a pants or slacks belt should not be used as a gait belt. During observation, a CNA placed a gait belt around the resident’s waist and assisted with pivot transfers from the wheelchair to the toilet, from the toilet to the wheelchair, and from the wheelchair to the bed while pulling on the gait belt and the back of the resident’s pants. The resident’s legs were unsteady during each transfer. Later, when a nurse responded to the resident’s call light and could not locate a gait belt, the nurse placed an arm around the resident’s back, assisted the resident to sit on the edge of the bed, placed a four-wheeled rolling walker in front of the resident, and asked her to stand. As the resident stood, her legs were unsteady and the walker rolled away as she sat back on the bed.
Failure to Maintain Ordered Oxygen During Transfers
Penalty
Summary
Failure to provide appropriate respiratory care occurred for one resident with an order for continuous oxygen via nasal cannula for oxygen saturation less than 88% for shortness of breath and low oxygen saturation levels. During observation, a CNA removed the resident’s nasal cannula while assisting the resident from a wheelchair to the toilet and back to the wheelchair. The resident appeared short of breath, and the surveyor asked the CNA to call the nurse to assess the resident’s respiratory status. When the nurse arrived 26 minutes later, the nurse obtained an oxygen saturation reading of 82%, and the CNA then applied the cannula back into the resident’s nostrils. After the oxygen was reapplied, the resident’s oxygen saturation varied between 92% and 94%.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information on 2 weekend days reviewed, March 14 and March 15, 2026. Observation on 03/15/26 at 12:15 p.m. showed staffing postings for Thursday 03/12/26 and Friday 03/13/26, but the facility had not updated the number of licensed and unlicensed staff working for Saturday 03/14/26 and Sunday 03/15/26. During an interview on 03/15/26 at 12:30 p.m., a charge nurse confirmed the staffing information had not been updated for Saturday and Sunday.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors resulted in an eight percent error rate, exceeding the facility requirement to keep the rate below five percent. During observation of 25 medications administered to 5 residents, two errors were identified for two residents. One nurse administered a resident’s levothyroxine at 8:21 a.m. with other morning medications and then assisted the resident to the dining room, where breakfast was eaten shortly afterward, rather than giving the medication on an empty stomach one half to one hour before breakfast as directed by prescribing information and facility policy. The same nurse also removed a 4% lidocaine pain patch from a box and applied it to another resident’s lower back, but the provider’s orders directed that the patch be applied to the resident’s back at bedtime and removed in the morning. The patch from the previous evening was not present on the resident’s back at the time of observation. During interview, the nurse confirmed failure to administer levothyroxine at least 30 minutes before breakfast on an empty stomach and failure to follow the provider’s orders when applying the lidocaine patch.
Unsecured medication cart and mismatched pantoprazole orders
Penalty
Summary
The facility failed to ensure medications and private health information were stored securely and failed to ensure medication labels matched provider orders for two residents observed during medication pass. On 03/15/26, the medication cart in the hallway outside the nurse's station was observed unlocked and unattended for about 5 minutes in a high-traffic area with staff and residents present. On 03/16/26, the medication cart in the 200 hallway was observed unlocked and unattended, and the electronic medication administration record (eMAR) was visible to staff and residents while a resident attempted to get around the cart. During medication pass on 03/17/26, a nurse prepared one resident's pantoprazole 40 mg daily medication, but the label instructed administration 30 minutes before breakfast while the eMAR did not include that instruction. Later that day, a medication aide prepared another resident's pantoprazole 40 mg medication, and the provider's order in the eMAR identified it as 40 mg daily at 5:00 p.m., while the medication label directed administration at 9:00 a.m. and 9:00 p.m. A staff nurse later confirmed that the pantoprazole medication labels did not match the residents' eMARs.
Failure to Monitor Parlor Freezer Temperature
Penalty
Summary
The facility failed to monitor freezer temperatures and follow safe storage practices for 1 of 3 freezer units. Review of the facility policy titled Food-Supply Storage-Food and Nutrition Services showed that freezer temperatures are to be 0 degrees Fahrenheit or lower and that internal temperatures of all freezers in the food and nutrition department, dining room, and nourishment areas are to be recorded twice daily. However, the facility document provided by administrative staff showed no documentation for monitoring the freezer temperatures of the freezer located in the parlor area from 12/01/25 through 03/09/26. During observation of the parlor area freezer, the temperature was 6 degrees Fahrenheit, and the administrative staff member removed and disposed of the remaining food from the freezer. During interview, the administrative staff member stated the expected freezer temperature was 0 degrees Fahrenheit or below.
QAPI Committee Missing Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) group had all required members attend meetings at least quarterly for 2 of 4 quarters reviewed, specifically November 2025 and February 2026. Review of QAPI meeting sign-in sheets from March 2025 through February 2026 showed that the medical director had not attended any meetings since August 2025. During an interview on 03/18/26 at 3:30 p.m., administrative staff member #8 confirmed that the medical director did not attend the required quarterly QAPI committee meetings.
Infection Control Lapses During Resident Care and Medication Administration
Penalty
Summary
The facility failed to follow infection prevention and control practices for one resident on enhanced barrier precautions and one supplemental resident during medication administration. The facility policy on hand hygiene stated that healthcare workers are to clean their hands when entering the patient room, before administering medications, before donning gloves, after removing gloves, and when exiting the patient room. The policy on standard, enhanced barrier, and transmission-based precautions stated that enhanced barrier precautions include the use of gowns and gloves during high-contact care activities, including transfers, providing hygiene, and changing briefs or assisting with toileting. Resident #24’s record identified enhanced barrier precautions related to chronic venous stasis ulcers. During observation, a CNA entered the resident’s room, performed hand hygiene, applied gloves, and assisted the resident with toileting, but did not wear a gown during this high-contact care. During another observation, a nurse prepared Resident #22’s medications, carried them into the resident’s room, and administered oral medications. The nurse then applied gloves to administer eye drops, removed the gloves, and exited the room without performing hand hygiene before or after glove use. The nurse later confirmed failing to appropriately perform hand hygiene during the medication pass.
Failure to Document Basis for Resident Transfer and Discharge
Penalty
Summary
The facility failed to provide appropriate discharge planning for Resident A and did not document the basis for the resident’s transfer and discharge in the medical record. Resident A had diagnoses including anxiety, depression, and a cerebral infarction, and was receiving Melatonin and Zoloft, which had been started for changes in behaviors and anxiety. The care plan stated the resident wished to remain in the center due to nursing care needs and included a pre-discharge planning intervention, but it did not identify an imminent discharge need related to behavioral changes. Resident A’s record showed a history of inappropriate sexual behaviors toward female residents and staff, including grabbing a CNA during care and prior incidents of inappropriate touching. The record also showed a care conference, a psychiatric referral, and a psych consult with an increased antidepressant dose, but the facility did not assess the resident’s behaviors after the medication change, revise the discharge plan, or consistently document an ongoing safety threat that would require immediate discharge. The resident was transferred to an acute care hospital and discharged from the facility the same day, and the record included a note that referrals were sent to multiple facilities for placement, but the facility could not provide documentation showing how many facilities were contacted, when they were contacted, or why they could not accept the resident.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative of an emergency room transfer for Resident #9. Review of the facility policy titled Discharge and Transfer Rehab/Skilled, Therapy & Rehab showed that the resident and the resident's representative are to be notified of a transfer or discharge and the reason for the move in writing and in a language and manner they understand. Review of the Hospital Transfer Checklist also stated to notify family or guardian and document in progress notes or the CICE. Review of Resident #9's medical record identified a transfer to the hospital on [DATE], but the facility did not provide a written transfer notice to the resident and/or representative. During interview, an administrative staff member confirmed the facility failed to notify the resident's representative of the transfer.
Failure to Prevent Worsening of Pressure Ulcers and Delayed Wound Care Referrals
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent the worsening of pressure ulcers for two residents with existing pressure ulcers. For one resident admitted with pressure ulcers to the left ankle and sacrum, the care plan included interventions such as encouraging and assisting with turning, and physician orders required repositioning every two hours and the use of protective boots while in bed. However, the medical record did not show evidence that staff consistently repositioned the resident or applied the protective boots as ordered. An administrative staff member confirmed the lack of documentation for these interventions. For another resident admitted with a diagnosis of spinal cord compression, the initial physician's orders did not identify or address pressure ulcers. Four days after admission, deep tissue injuries to both buttocks were identified, and wound care orders were obtained the following day. The care plan was not updated to include a repositioning schedule until approximately one month after the injuries were first noted, despite wound assessments recommending repositioning every 2-3 hours. The medical record lacked evidence that staff implemented the recommended repositioning schedule. Additionally, the facility failed to process and coordinate timely referrals for wound care. There were delays in following up on wound clinic referrals, and the provider did not evaluate the resident's wound during a bedside visit. The resident's wounds deteriorated, progressing to a stage 4 pressure injury with acute cellulitis, and required hospitalization. The facility also did not provide a policy for processing referrals to outside agencies, contributing to the delay in wound care follow-up.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents during a staff-assisted transfer for one resident. Specifically, staff did not use a gait belt while transferring a resident from a wheelchair to a recliner, despite the resident's care plan indicating a need for assistance due to self-care performance deficits related to weakness. During the transfer, the resident's knees gave out, resulting in an assisted fall in which the resident struck her head on a dresser and subsequently sustained a right hip fracture. The incident was documented in the facility's reported incident and medical records, which noted the resident experienced significant pain and was sent to the emergency room for evaluation. The facility's policy on gait belt use, which was in effect at the time, required gait belts to be used during transfers to aid patients and protect them from accidental trauma. The failure to follow this policy and utilize the gait belt during the transfer directly led to the resident's fall and injury.
Unqualified Dietary Manager Directing Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the individual serving as the dietary manager had obtained the required qualifications to direct the food and nutrition services. During an interview, the dietary manager stated that he was currently enrolled in a certified dietary manager course but had not yet completed it. As a result, the facility did not have a dietary manager who had completed the necessary education or held a national certification for food service management and safety, as required.
Failure to Implement Effective QAPI Process
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems, improve services and outcomes, and ensure compliance with federal requirements. Review of state agency files showed the facility did not maintain compliance in several areas, including care plan timing and revision, bowel/bladder incontinence, sufficient nursing staff, medication errors, and food procurement and sanitation, as evidenced by deficiencies cited during the last standard survey. During staff interviews, an administrative staff member indicated that while departments conducted various audits monthly, there was a lack of awareness regarding monitoring of the specific areas cited, except for care planning. This lack of an effective QAPI process resulted in continued noncompliance in the identified areas.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to employ an individual who had completed specialized training in infection prevention and control to be responsible for the Infection Prevention and Control program. Review of the facility's policy confirmed that the Infection Preventionist must have completed such specialized training. During staff interviews, an administrative nurse confirmed that no staff member with the required specialized training was employed to oversee the infection prevention and control program. This deficiency was identified through review of employee files, facility policy, and staff interviews.
Failure to Update and Revise Care Plans to Reflect Residents' Current Needs
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of four residents. For one resident, the care plan did not include required blood sugar monitoring and did not update oxygen needs as per the physician's order. Another resident's care plan listed Enhanced Barrier Precautions (EBP) without documenting a related diagnosis or problem, and failed to address pain management despite an active order for oxycodone. A third resident's care plan did not identify the problem or interventions related to edema, even though the resident was prescribed furosemide for this condition. Additionally, a fourth resident's care plan incorrectly documented the fluid restriction, listing 200 cc instead of the physician-ordered 2000 cc with specific allocations for dietary and nursing shifts. These omissions and inaccuracies were confirmed by administrative staff during interviews, and the facility's policy requires care plans to be updated as residents' needs or statuses change. The lack of timely and accurate care plan updates limited staff's ability to communicate resident needs and ensure continuity of care.
Insufficient Nursing Staff Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and related services to meet the needs of all residents, as evidenced by multiple documented concerns from resident council meeting minutes, resident and family interviews, and staffing record reviews. Residents reported excessive wait times for assistance with toileting, lack of clean towels over weekends, delayed trash removal, and call lights being turned off without addressing their needs. Specific accounts included residents waiting up to an hour for call light responses, experiencing incontinence due to delays, and staff shortages, particularly with only one CNA on the floor at times. Staff interviews confirmed that CNA staffing was only increased after a recent census rise, and staffing records showed that the facility did not consistently maintain the increased CNA coverage, missing adequate staffing on four days and lacking a bath aide on two days within a 13-day period. These findings were corroborated by both resident and family observations of insufficient staff and prolonged wait times for care.
Failure to Consistently Provide and Distribute Snacks to Residents
Penalty
Summary
The facility failed to provide snacks to residents in accordance with their needs and preferences, as evidenced by observations, resident council meeting minutes, and interviews. Resident council minutes over several months documented ongoing concerns about the inconsistency of evening snack distribution, with residents reporting that snacks were not reliably passed and that they often had to request them. One resident, who is diabetic, specifically noted that snacks were left at the nurse's station and not delivered to residents' rooms, which occurred frequently and impacted their ability to manage their condition. On the day of observation, snacks were seen being delivered to the nurse's station but not distributed to residents. A resident was observed removing the plastic wrap and touching multiple snack bars on the cart while staff were present, raising concerns about food safety. Another resident requested a snack from a CNA, who attempted to provide it but was informed that the snacks had been touched by another resident. The dietary manager confirmed that while the kitchen provides snacks, they are only placed at the nurse's station and not delivered to residents, indicating a lack of clear responsibility for snack distribution.
Improper Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage practices within the facility's kitchen. The walk-in freezer had condensation and ice build-up on the ceiling and floor, with boxes of food placed directly on the iced floor. Additionally, the walk-in refrigerator contained a closed medication box and an unopened bottle of cola, both identified as belonging to a dietary staff member. The dietary manager confirmed that these personal items should not have been stored in the kitchen refrigerator, as there is a designated employee refrigerator for such items. Further inspection revealed six large bundles of flowers stored in the walk-in refrigerator. Facility policies require all food and supply items to be stored at least six inches off the floor and prohibit employee food, fluids, and personal items from being stored in kitchen coolers, freezers, or dry storage. The FDA Food Code also mandates that food be protected from contamination by proper storage in clean, dry locations and away from potential sources of contamination. Administrative staff confirmed that kitchen coolers are to remain free from personal items, medications, and flowers, indicating that these observations were in direct violation of both facility policy and professional standards.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically sexual abuse, as evidenced by repeated incidents involving a resident with severe cognitive impairment who displayed inappropriate sexual behaviors towards other residents. The care plan for this resident acknowledged a history of inappropriate sexual advances and included interventions such as redirection, monitoring, and reporting new behaviors to a health care provider. Despite these interventions, the resident was involved in multiple incidents where he touched female residents inappropriately, including touching a resident's breast and rubbing another resident's upper thigh. These incidents were witnessed by staff, who intervened at the time, and were documented in the resident's progress notes and facility investigation reports. Interviews with female residents revealed that the inappropriate touching had occurred on more than one occasion, with some residents stating that the behavior had been ongoing for about a month. The facility's investigation and documentation did not recognize these behaviors as sexual abuse, nor did they update or implement additional interventions to prevent further occurrences. The affected residents, including one with dementia and memory problems, were vulnerable due to their cognitive impairments. The facility's failure to identify and address the behaviors as sexual abuse resulted in a deficiency related to protecting residents from abuse.
Failure to Report Resident-to-Resident Sexual Abuse Incidents
Penalty
Summary
The facility failed to report incidents of resident-to-resident sexual abuse to the State Survey Agency as required by policy. Specifically, a resident with severe cognitive impairment was documented in the medical record and care plan as having displayed inappropriate sexual advances toward another resident. Progress notes detailed two separate incidents in which the resident was observed touching or rubbing a female resident's leg and upper thigh. In both cases, staff intervened, separated the residents, and provided education to the resident involved. Despite these documented incidents, there was no evidence that the facility reported the events to the State Survey Agency. The facility's policy requires prompt reporting and investigation of all suspected or alleged abuse, including notification of designated agencies. During staff interviews, it was revealed that supervisory staff were not informed of at least one of the incidents, further contributing to the failure to report as required.
Inaccurate MDS Coding for Diagnoses and Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident with a history of benign prostatic hyperplasia (BPH) and a chronic indwelling Foley catheter, the annual MDS identified the presence of the catheter but did not indicate the related diagnosis of BPH or urinary obstruction, despite documentation in the medical record and care plan. An MDS nurse confirmed that staff did not code the relevant diagnoses on the MDS. Additionally, two other residents who were prescribed and administered daily aspirin, an antiplatelet medication, were not coded for antiplatelet use on their quarterly MDS assessments. This omission was confirmed by an administrative staff member. The failure to accurately code both diagnoses and medication use on the MDS assessments means the residents' current statuses were not fully reflected in their assessments.
Failure to Develop Accurate Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to implement a baseline care plan that accurately reflected the immediate needs of a newly admitted resident. Record review showed that the resident had diagnoses of diabetes and hydrocephalus, with physician orders for Lantus Solo Star (insulin) for blood sugar management and Acetazolamide ER for obstructive hydrocephalus. The baseline care plan, however, incorrectly identified Acetazolamide as a treatment for diabetes, did not address the use of insulin, and omitted interventions for blood sugar irregularities. Additionally, the care plan failed to correctly identify the use of a diuretic and did not include interventions for complications related to hydrocephalus. During staff interviews, administrative staff confirmed that an accurate baseline care plan was not developed for the resident. The facility's policy required the use of pre-admission and admission information to develop an initial care plan with specific interventions, but this was not followed, resulting in a care plan that did not address the resident's actual clinical needs as documented in the medical record and physician orders.
Failure to Supervise Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to provide adequate supervision and enforce smoking policies for a resident who smoked, resulting in repeated incidents of smoking in unauthorized areas. The resident, who was assessed as safe to smoke independently and permitted to have two cigarettes at a time, was found smoking inside the building and in entryways on multiple occasions. Documentation showed that staff instructed the resident to use the designated outdoor smoking area, but the resident continued to smoke in prohibited locations, including inside the facility and just outside entry doors. The care plan required staff to check the resident for cigarettes and lighters upon return from smoking and to store these items at the nurse's station. Observations during the survey revealed that cigarettes and lighters were stored in an unlocked storage room in an open box, with the key left in the lock, contrary to facility policy. Interviews with staff indicated a lack of awareness and inconsistent enforcement of the policy requiring the box to be locked and the key kept in the nurse's medication cart. Administrative staff confirmed that the resident should not be smoking inside or near the building, and that the current storage practices for smoking materials did not align with facility expectations.
Failure to Provide Scheduled Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate toileting care for two residents who required staff assistance due to conditions such as multiple sclerosis and bipolar disorder. Both residents were identified as incontinent and had care plans specifying the need for scheduled toileting and assistance with incontinence care. Despite these care plans, observations revealed that staff did not consistently check or change the residents, encourage toileting, provide education, or notify nursing staff when residents refused care. For one resident with multiple sclerosis, staff offered toileting and repositioning multiple times, but the resident refused each time. However, the certified nurse aide did not check the resident's brief, encourage further toileting or repositioning, provide education about the importance of care, or notify the nurse of the refusals. Review of toileting records showed multiple instances where the resident was not checked, changed, or toileted for extended periods, including two days with no care for 24 hours and several days with only one or two checks in a 24-hour period. Another resident with bipolar disorder and impaired thought processes was observed with signs of soiling and a strong odor of feces, yet staff did not immediately provide care or notify nursing. The resident frequently refused toileting, and staff indicated that they would simply return later. Only after prompting from the surveyor did the CNA notify the nurse, who then provided the necessary assistance. The toileting record for this resident also showed several days with no checks or changes for 24 hours and many days with minimal care. Staff interviews confirmed that refusals were not consistently documented or reported to nursing as required.
Lack of Post-Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident receiving dialysis. According to facility policy, dialysis care should be individualized to the resident, including care planning for unique nutritional needs, fluid restrictions, and specific instructions such as avoiding blood pressure measurements and blood draws from the arm with a fistula. The resident in question had a care plan and nursing orders specifying the need for clinical monitoring before and after dialysis sessions, as well as instructions to monitor for signs and symptoms of complications such as bleeding, hemorrhage, and infection. Despite these requirements, the medical record did not contain documentation of communication from the dialysis unit regarding the resident's condition during and after dialysis treatments. Staff interviews confirmed that while information such as an order sheet, medication list, and care plan were sent with the resident to the dialysis facility, no handoff communication was received from the dialysis unit about the resident's status post-treatment. This lack of communication resulted in a failure to properly monitor and document the resident's condition as required.
Medication Error Rate Exceeds Five Percent Due to Improper Administration Practices
Penalty
Summary
Surveyors identified that the facility failed to maintain a medication error rate below five percent during medication administration observations. Specifically, out of 26 medications administered to five residents, four errors were observed, resulting in a fifteen percent error rate. For one resident, a medication aide crushed both a delayed-release calcium/magnesium supplement (Slow-Mag) and an extended-release Isosorbide Mononitrate tablet, despite facility policy and manufacturer instructions stating these medications should not be crushed. The aide placed the crushed medications into pudding and administered them to the resident. Additionally, a nurse was observed preparing insulin pens for two residents and failed to prime the pens correctly. Instead of holding the insulin pen with the needle pointing upwards as required by facility policy, the nurse primed the pens with the needle pointed down and dispensed the insulin into a sink. An administrative staff member confirmed that staff are expected to prime insulin pens vertically and not to crush delayed or extended-release medications.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the posting of accurate nurse staffing information on all four days of the survey, specifically from February 10 to February 13, 2025. Observations revealed that the Daily Staffing form, which was posted in the hallway by the residents' dining room, did not accurately reflect the number of unlicensed staff working each shift during this period. Review of the posted forms confirmed the inaccuracies, and during an interview, both an administrative nurse and the staffing scheduler acknowledged that the daily staffing forms were incorrect. No specific residents or patient medical histories were mentioned in relation to this deficiency. The deficiency was identified through direct observation, record review, and staff interviews.
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.
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