Minot Health And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Minot, North Dakota.
- Location
- 600 S Main St, Minot, North Dakota 58701
- CMS Provider Number
- 355031
- Inspections on file
- 26
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Minot Health And Rehab, Llc during CMS and state inspections, most recent first.
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.
A resident with severe expressive aphasia and anxiety disorder, dependent on staff for toileting, was left on a bedside commode for approximately six hours without the call light within reach or regular checks by CNAs. This resulted in skin discoloration to the buttocks and a wrist bruise from attempting to get help, as the care plan requiring call light placement and monitoring was not followed.
A resident with severe expressive aphasia and dependent on staff for toileting was left on a bedside commode for an extended period, resulting in skin redness and a bruise from attempting to get help. The incident, which met the facility's criteria for reporting suspected neglect, was not reported to the State Survey Agency as required by policy.
Multiple failures were observed in maintaining a safe, clean, and homelike environment, including non-functioning lights, soiled privacy curtains, visible dust and debris, torn wallpaper, and makeshift repairs with tape. Staff interviews confirmed that cleaning and maintenance procedures were not consistently followed, and required reporting of maintenance issues was not always completed.
The facility did not provide required written transfer and bed-hold notices, including reserve bed payment information, to several residents or their representatives during hospital transfers, and failed to notify the State Long Term Care Ombudsman as required. Documentation reviews and staff interviews confirmed these omissions.
Surveyors found that the facility did not accurately code the MDS for several residents, including failing to document serious mental illness, hospice care, depression diagnosis, correct discharge location, and wound dressing treatments, despite supporting medical records and physician orders.
Facility staff did not transcribe a physician's order for multiple blood tests into the electronic medical record and did not ensure the collection of the required blood specimens for a resident. Administrative staff confirmed the omission, and there was no documentation that the laboratory tests were completed.
A resident dependent on staff for bathing did not consistently receive scheduled baths, as evidenced by unclean fingernails and incomplete documentation of bathing assistance. Family concerns and staff interviews confirmed lapses in both care provision and record-keeping.
Two residents receiving hospice services did not have the required hospice election forms in their medical records, despite documentation of hospice enrollment and admission. Facility policy and the hospice contract both require these forms to be obtained and maintained, but an administrative nurse confirmed their absence.
A staff member at the facility took inappropriate images and videos of residents, leading to a failure to protect them from sexual and mental abuse. This affected multiple residents, some with cognitive impairments. The facility's policies on abuse and social media use were not effectively enforced, resulting in an Immediate Jeopardy situation.
A resident with severely impaired cognition due to dementia and Parkinson's disease experienced non-consensual sexual contact from another cognitively intact resident. The incident was observed by a staff member, who reported that the affected resident appeared distressed and attempted to swat the other resident away. The facility's policy on abuse, neglect, and exploitation was not effectively implemented to prevent this incident.
A resident developed a stage IV pressure ulcer with exposed hardware due to the facility's failure to evaluate risk factors and implement necessary interventions. The resident, admitted post-surgery for a broken ankle, did not receive proper wound assessment and monitoring, leading to the ulcer's progression. Staff failed to document changes in the wound status and did not complete required assessments.
The facility failed to accurately code the MDS for several residents, affecting the accuracy of assessments and care plans. A resident with Bipolar II Disorder was not correctly coded in the PASRR section, while another resident's medication coding inaccurately reflected insulin use. Additionally, a resident's diuretic use was not recorded. These errors were confirmed by staff interviews.
The facility did not follow professional standards for insulin administration for two residents. A nurse failed to keep the needle in the skin for the required time after administering insulin, and another nurse did not prime an insulin pen according to policy. These actions could lead to inaccurate dosing.
A facility failed to ensure accurate labeling of insulin pens during medication administration for a resident. A nurse prepared insulin and removed a plastic bag labeled with the resident's name from the medication cart, containing NovoLog and Tresiba insulin pens. The NovoLog pen lacked a medication label with the resident's name and administration instructions, and the Tresiba pen lacked an open date. This was against the facility's policy, which requires documenting the open date on the pen body and verifying that the medication label matches the MAR. An administrative nurse confirmed the expectation for staff to follow this policy.
A facility failed to notify a resident's representative of care conferences and did not inform a physician about another resident's high blood sugar levels. The facility's policy requires notifying representatives and physicians of significant changes, but records showed no evidence of such notifications. Interviews confirmed these communication failures, which could prevent appropriate care planning.
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 Follow Care Plan for Toileting and Call Light Placement
Penalty
Summary
Staff failed to follow the care plan for a resident with severe expressive aphasia and anxiety disorder, who was dependent on staff for toileting. The care plan specifically required that the call light be secured to the bedside commode and within reach when the resident was toileting. On the evening in question, two certified nurse aides transferred the resident to the bedside commode but did not place the call light within reach and did not check on the resident for approximately six hours. As a result of these actions, the resident was found on the commode after an extended period, with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident, who was unable to verbalize needs due to aphasia, was left without a means to call for help and was not monitored as required by the care plan.
Failure to Report Suspected Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect to the State Survey Agency as required by its own policy and federal regulations. A resident with a history of anxiety disorder and severe expressive aphasia, who was dependent on staff for toileting, was found left on a bedside commode for an extended period of time. The care plan for this resident specified the need to ensure the call light was secured and within reach during toileting due to impaired communication. A progress note documented that the resident was found with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident denied pain and showed no signs or symptoms of pain at the time of assessment. Despite these findings, the facility did not report the incident to the State Survey Agency as required by their policy, which mandates immediate reporting of all alleged violations of abuse or neglect. An administrative nurse confirmed during an interview that the incident was not reported. The failure to report this incident constitutes a deficiency in the facility's compliance with abuse and neglect reporting requirements.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and homelike environment for residents. Observations revealed issues in several resident rooms, including a non-functioning bathroom light that had been out for about two weeks despite being reported to staff, visible dust and debris on ceiling vents, soiled wallpaper, torn wallpaper, and missing or broken equipment such as a thermostat and a ceiling light cover. Some rooms had makeshift repairs, such as masking or painter's tape with dried paint on doors and window screens with holes patched by residents themselves. In one case, a privacy curtain was visibly soiled with what a resident identified as blood, and the curtain had not been cleaned or replaced as required by facility policy. Interviews with staff confirmed that cleaning and maintenance procedures were not consistently followed. The housekeeping supervisor acknowledged that privacy curtains are supposed to be cleaned weekly and when visibly soiled, but confirmed that a soiled curtain remained in place. Administrative staff admitted that painter's tape was not removed in a timely manner and that maintenance concerns, such as missing light covers and non-functioning lights, were not reported as expected. The facility's own policies and housekeeping checklists require regular cleaning, spot-cleaning of walls, and prompt attention to visible dirt or damage, but these standards were not met in the sampled rooms and storage areas.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers and bed-hold policies for multiple residents who were hospitalized. Specifically, for four sampled residents and one closed record, the facility did not provide the residents or their representatives with written notices of transfer or bed-hold, nor did they notify the State Long Term Care Ombudsman as required. In several cases, the bed-hold notices that were provided lacked the required information about the reserve bed payment amount, and transfer notices did not show evidence of Ombudsman notification. These deficiencies were identified through record reviews, policy reviews, and staff interviews. The review of facility policies confirmed that written information regarding bed-hold practices and transfer notifications, including the reserve bed payment policy and Ombudsman notification, should be provided at the time of transfer for hospitalization. However, documentation for the sampled residents showed missing or incomplete notices for hospitalizations, with some records lacking any notice and others missing specific required details. An administrative nurse confirmed during interviews that the required documentation was not present in the records reviewed.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for several residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. Specific deficiencies included not identifying a serious mental illness for a resident with a qualifying PASRR Level II screening, incorrectly coding a resident's discharge location as a nursing home instead of home, and omitting an active diagnosis of depression for a resident receiving antidepressant medication. Additionally, a resident admitted to hospice care was not coded as terminally ill or as receiving hospice services on the MDS, and another resident's application of dressings to lower extremity wounds was not documented in the MDS despite treatment records confirming the care was provided. These inaccuracies in MDS coding were confirmed by an administrative nurse and were found across multiple sections, including identification information, active diagnoses, health conditions, skin conditions, and special treatments. The errors were substantiated by medical records, physician orders, treatment administration records, and progress notes, all of which demonstrated discrepancies between the care provided or resident status and what was documented in the MDS assessments.
Failure to Transcribe Physician's Orders and Complete Laboratory Tests
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards for one resident by not transcribing a physician's order for six blood tests into the electronic medical record and not ensuring the collection of the required blood specimens. The physician's order, dated 03/26/25, was present in the resident's medical record, but there was no documentation that the laboratory tests had been completed. During interviews, administrative staff confirmed that the order was not transcribed and the blood specimens were not collected as required.
Failure to Provide Scheduled Bathing Assistance and Maintain Documentation
Penalty
Summary
The facility failed to provide necessary assistance with bathing for a resident who was dependent on staff for activities of daily living due to weakness. A family member reported concerns about the resident's personal hygiene, specifically noting unclean fingernails and questioning whether scheduled weekly baths were being provided. Observations confirmed the presence of dark areas under the resident's fingernails on two consecutive days. Review of the resident's care plan indicated the need for staff assistance with bathing and transfers. Documentation for March, April, and May showed inconsistent records of completed or refused baths/showers, with several instances lacking any documentation of whether bathing was provided or refused. An administrative nurse confirmed the absence of required documentation for scheduled bathing assistance.
Missing Hospice Election Forms in Resident Records
Penalty
Summary
The facility failed to ensure that the medical records of two residents receiving hospice services contained the required hospice election forms. Review of the hospice contract and facility policy confirmed that providing and obtaining the hospice election form is a responsibility of both the hospice agency and designated facility staff. For one resident, a nurse's note documented enrollment in hospice for end-of-life care, but the corresponding hospice election of benefits form was missing from the medical record. For the second resident, both a physician's order for hospice admission and a nurse's note confirming hospice admission were present, yet the hospice election form was also absent from the record. An administrative nurse verified that both records lacked the necessary documentation.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from sexual and mental abuse, as evidenced by the actions of a staff member who took inappropriate images and videos of residents. This deficiency affected five current residents and one former resident, as identified through a review of a staff member's electronic device. The inappropriate actions were discovered when law enforcement notified the facility of the staff member's arrest, revealing the presence of these images and videos. The facility's policy on abuse, neglect, and exploitation, as well as its policy on employee social media use, were not effectively implemented or enforced. The policies clearly prohibit the taking and sharing of unauthorized photographs or recordings of residents, especially those that could demean or humiliate them. Despite these policies, a staff member engaged in such behavior, leading to the identification of multiple residents in the inappropriate content. The residents involved had varying levels of cognitive impairment, with some having intact cognition and others being moderately to severely impaired. The failure to protect these residents from abuse was identified as an Immediate Jeopardy situation, indicating a serious threat to their health and safety. The deficiency was considered past non-compliance as corrective actions were taken prior to the survey.
Removal Plan
- Terminated staff member (#2).
- Educated all staff on-duty and all on-coming staff on facility's policy/procedure for abuse, neglect and exploitation, and social media use.
- Completed assessments of all residents.
- Notified the medical director.
- Reviewed facility policies and resources and updated as necessary.
- Interviewed all staff to identify any allegation of misconduct to include taking of inappropriate photos/videos of residents.
- Maintained contact with law enforcement agencies to identify possible affected residents and appropriate next steps.
- Implemented behavior monitoring for all residents identified.
Failure to Protect Resident from Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to protect a resident from non-consensual sexual contact by another resident. The incident occurred when a staff member observed one resident with his hand down the front of another resident's pants. The resident who was subjected to the unwanted contact appeared distressed and attempted to swat the other resident away. The resident who initiated the contact was cognitively intact, while the resident who experienced the unwanted contact had severely impaired cognition due to dementia and Parkinson's disease. The incident was reported to the nursing staff, Executive Director, and social services, and local law enforcement was notified. The resident who experienced the unwanted contact was able to briefly describe the incident and reported not feeling in danger. The facility's policy on abuse, neglect, and exploitation, which prohibits non-consensual sexual contact, was not effectively implemented to prevent this incident.
Removal Plan
- Implemented 1 to 1 staff supervision/monitoring for Resident #1.
- Moved Resident #1's roommate to another room.
- Reeducated staff regarding 1 to 1 supervision and on the abuse, neglect, and exploitation policy.
- Interviewed other residents to determine if any other abuse occurred.
- Reported the concern to the North Dakota Department of Health and Human Services.
- Reported the concern to local Police Department.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of a pressure ulcer for a resident identified as having a stage IV pressure ulcer with exposed hardware. The facility did not evaluate risk factors that could impact the development of a pressure ulcer, nor did they implement, monitor, and modify interventions to reduce those risk factors. This resulted in the resident developing an avoidable, facility-acquired pressure ulcer. The resident was admitted to the facility following a fall and surgery for a broken right ankle. The facility's policy required regular skin assessments and documentation of any changes in wound status, appearance, color, wound healing, signs of infection, wound size, and stage. However, the staff failed to address the surgical incision on the resident's right ankle during daily dressing changes and did not document or report any changes in the wound status. The resident's progress notes indicated that the surgical wound was not properly assessed or monitored, leading to the development of a stage IV pressure ulcer with 80% hardware exposure. The facility did not identify the pressure ulcer before it progressed to this severe stage, and the staff failed to document wound measurements on the admission skin assessment and complete non-pressure weekly tracker assessments.
Removal Plan
- Assess the pressure ulcer to Resident #138 right ankle.
- Complete an investigation into the facility acquired pressure ulcer.
- Determine nursing staff failed to document wound measurements on the admission skin assessment.
- Determine nursing staff failed to complete non-pressure weekly tracker assessments.
- Determine nursing staff removed pressure relieving interventions from the care plan.
- Educate Resident #138 regarding the need for pressure relieving interventions.
- Update Resident #138's care plan.
- Audit other residents with surgical wounds and/or cam boots.
- Update other residents' care plans.
- Educate staff regarding skin injuries and interventions.
- Add surgical skin areas and wounds to the wound tracker (computer program).
- Complete audits on skin injuries.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four of the twelve sampled residents, which affected the accuracy of resident assessments and potentially the development of comprehensive care plans. For Resident #18, the facility did not correctly code the Preadmission Screening and Resident Review (PASRR) section, despite a PASRR Level II Outcome indicating a diagnosis of Bipolar II Disorder. This error was confirmed by a social services staff member during an interview. Additionally, the facility made errors in coding the medication sections for Residents #2 and #28. Resident #2's MDS was incorrectly coded to reflect seven days of insulin injections, although the resident was receiving Trulicity, a non-insulin medication, once a week. This mistake was acknowledged by an MDS coordinator. Similarly, Resident #28's MDS failed to indicate the use of a diuretic, despite physician orders for daily Chlorthalidone. This error was also confirmed by an MDS coordinator.
Failure to Follow Insulin Administration Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice for insulin preparation and administration for two residents. During an observation, a nurse prepared a NovoLog insulin pen for a resident and administered the insulin by inserting the needle into the resident's abdomen and pressing the injection button until the dose selector reached 0. However, the nurse did not keep the needle in the skin for up to 10 seconds as required by the facility's policy. In another instance, a different nurse prepared an Asepet insulin pen for another resident and primed the pen horizontally by dialing it to 2, which did not comply with the facility's policy for priming insulin pens. These actions resulted in a failure to follow the facility's insulin administration policy, potentially leading to inaccurate dosing.
Medication Labeling Deficiency During Insulin Administration
Penalty
Summary
The facility failed to ensure accurate labeling of medications during the administration of insulin for one resident. During an observation, a nurse prepared insulin for a resident and removed a plastic bag labeled with the resident's name from the medication cart. The bag contained NovoLog and Tresiba insulin pens. However, the NovoLog pen lacked a medication label with the resident's name and administration instructions, and the Tresiba insulin pen lacked an open date. This was contrary to the facility's policy on insulin administration, which requires documenting the open date on the pen body and verifying that the medication label matches the Medication Administration Record (MAR). An administrative nurse confirmed that staff are expected to follow the facility policy to ensure insulin pens have a label and an open date.
Failure to Notify Resident Representative and Physician
Penalty
Summary
The facility failed to notify the resident representative of a care conference for a resident who was reviewed for care conferences. The facility's policy requires that the comprehensive care plan be prepared by an interdisciplinary team, including the resident and the resident's representative, to the extent practicable. However, the medical record of the resident identified a representative as the primary power of attorney for medical and financial decisions, but there was no evidence that the facility notified this representative of the care conference. An administrative staff member confirmed the failure to notify the resident's representative. Additionally, the facility failed to notify a physician of a change in condition for a resident who experienced high blood sugar levels. The facility's policy mandates that when a resident presents with a possible change of condition, such as elevated blood glucose levels, the resident's physician should be notified. The medical record of the resident, who had a diagnosis of type 2 diabetes mellitus with hyperglycemia, showed multiple instances of blood sugar readings above the ordered parameters. Despite this, there was no evidence that the facility notified the resident's physician of these high readings. Interviews with administrative nurses confirmed that the facility staff failed to notify the physician of the high blood sugar readings. The lack of notification could prevent the physician from evaluating and prescribing an appropriate treatment plan. The resident's representative also stated that they had not been contacted regarding the resident's care plans or significant changes in the resident's status, further highlighting the communication deficiencies within the facility.
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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