St Gerard's Community Of Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Hankinson, North Dakota.
- Location
- 613 1st Ave Sw, Hankinson, North Dakota 58041
- CMS Provider Number
- 355038
- Inspections on file
- 15
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at St Gerard's Community Of Care during CMS and state inspections, most recent first.
Staff did not adhere to facility policy for insulin pen preparation and administration for three residents. Insulin pens were primed with the needle cap on, held horizontally, and in some cases, with an incorrect number of units, rather than following the required procedure of removing the cap, holding the pen upright, and dialing the correct dose.
Staff failed to consistently follow infection control protocols, including proper use of enhanced barrier precautions and hand hygiene, during high-contact care activities for three residents. Incidents included not wearing required PPE, not performing hand hygiene after glove removal, and not offering hand hygiene to residents during perineal and device care.
A resident with severe dementia engaged in unwanted physical contact with other residents, including kissing and touching, without their consent. The facility lacked adequate care plans and interventions to manage the resident's behavior and protect others. Staff failed to recognize and report these interactions as potential abuse, indicating a lack of awareness and training. The facility's policy required assessment and care planning for residents with behaviors that may lead to conflict, but this was not effectively implemented.
A facility failed to investigate incidents of resident-to-resident abuse involving three cognitively impaired residents. An Immediate Jeopardy situation was identified when a resident was observed engaging in inappropriate physical contact with others. Despite facility policy requiring immediate investigation of abuse, staff failed to report and investigate the incidents, leaving residents vulnerable to further harm.
The facility failed to protect 31 residents by not screening unlicensed employees prior to employment, placing them at risk for abuse, neglect, and exploitation. Despite a policy requiring background checks, the facility relied on applicants' honesty and community word-of-mouth instead of conducting thorough screenings. The administrator admitted the lack of a system to verify non-licensed staff's criminal history, leading to a deficiency in resident protection.
A facility failed to report incidents of resident-to-resident abuse involving residents with cognitive impairments. One resident was observed being touched by another despite family objections, and another resident with severe dementia was seen kissing and touching others without consent. Staff did not report these incidents to the administration or SSA, violating facility policy.
The facility failed to update care plans for two residents, impacting care delivery. One resident's plan lacked details on water restrictions related to medication and OCD, while another's plan omitted necessary transfer equipment, contrary to physician's orders. Observations confirmed these deficiencies, with staff interviews highlighting the need for individualized care plans.
The facility failed to provide adequate assistance during mechanical lift transfers for two residents, leading to potential risks of pain and discomfort. A resident with muscle weakness was improperly transferred using the EZ Way stand lift without the correct use of the seat strap, causing discomfort. Another resident with dementia was transferred without the required seat and leg straps. Additionally, the facility did not complete a thorough investigation for a resident with a history of falls and a recent fracture, failing to update the care plan and implement corrective actions.
The facility failed to ensure proper infection control practices, as observed with two CNAs who did not disinfect a sit-to-stand lift between resident uses and did not perform appropriate hand hygiene. One CNA acknowledged the failure to wash hands and change gloves during care, while another believed housekeeping was responsible for cleaning the lift.
Failure to Follow Insulin Pen Priming Protocols
Penalty
Summary
Staff failed to follow professional standards of practice for insulin pen preparation and administration for three residents. Facility policy required staff to prime the insulin pen by dialing 2 units, removing the needle cap, and holding the pen upright to ensure a drop of insulin appeared at the needle tip. However, observations revealed that a nurse primed insulin pens for two residents by dialing 3 units instead of 2, left the needle cap on, and held the pen horizontally rather than upright. Similarly, a medication aide primed an insulin pen for another resident by dialing the correct 2 units but also left the needle cap on and held the pen horizontally. These actions were directly observed during insulin administration for all three residents. During an interview, an administrative staff member confirmed that the expected practice was to prime the pen with the cap off and the needle pointed upward, as per facility policy. The failure to follow these procedures resulted in a deficiency related to not meeting professional standards of quality for medication administration.
Failure to Follow Infection Control Standards During Resident Care
Penalty
Summary
Surveyors identified failures in infection prevention and control practices for three residents during observed care activities. For one resident with a colostomy and catheter, a CNA donned appropriate PPE and performed hand hygiene after changing the colostomy bag, but a nurse who assisted with the procedure failed to apply a gown before providing care and did not perform hand hygiene prior to donning gloves. The facility's policy required enhanced barrier precautions, including gown and gloves, for high-contact care activities involving indwelling medical devices, which was not followed in this instance. Additional observations revealed that a CNA did not perform hand hygiene after removing soiled gloves and before applying a clean brief to another resident during perineal care. In a separate incident, a CNA assisted a resident with toileting, removed soiled gloves, and then applied clean gloves without performing hand hygiene, and also did not offer hand hygiene to the resident. These actions were inconsistent with the facility's infection control policies, which require hand hygiene after glove removal and between procedures.
Failure to Prevent Resident-to-Resident Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents with impaired cognition from resident-to-resident abuse, as evidenced by the interactions involving Resident #24 and other residents. Resident #24, who has a diagnosis of severe dementia and severely impaired cognition, was observed engaging in physical contact with other residents, including kissing and touching, without their consent. The facility did not have adequate care plans or interventions in place to manage Resident #24's behavior or to protect other residents from unwanted contact. Resident #24's care plan allowed for consensual acts of hand-holding and hugging in public areas, but it did not address the resident's behavior of entering female residents' rooms or the potential for unwanted physical contact. Despite previous incidents where Resident #24 entered rooms and engaged in physical contact, the facility did not update the care plan to include interventions to prevent such behavior. Additionally, staff failed to recognize and report these interactions as potential abuse, indicating a lack of awareness and training on identifying and managing resident-to-resident abuse. The facility's policy on abuse, neglect, and exploitation required staff to assess, monitor, and develop appropriate care plans for residents with behaviors that may lead to conflict. However, the facility did not have a system in place to assess all residents' needs and preferences, resulting in inadequate care planning and monitoring. This oversight led to multiple incidents where residents with impaired cognition were subjected to unwanted physical contact, causing potential fear, anxiety, and psychosocial harm.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate incidents of resident-to-resident abuse involving three residents with impaired cognition who were unable to consent. During the on-site recertification survey, an Immediate Jeopardy (IJ) situation was identified when a nurse's note revealed that a resident had kissed two female residents on the cheek. An observation showed the same resident engaging in inappropriate physical contact with another resident, who remained non-verbal throughout the incident. These actions placed the residents in immediate danger of fear, anxiety, or psychosocial harm. The facility's policy on abuse, neglect, and exploitation requires immediate investigation when abuse is suspected or reported. However, the staff failed to report and investigate the incidents involving the resident's inappropriate behavior. Interviews with staff and family members revealed that the facility was aware of the resident's behavior but did not take appropriate action to prevent further incidents. The family of one resident had explicitly stated they did not want the resident to be touched, but their wishes were not respected. The medical records of the involved residents indicated severe cognitive impairments, making them vulnerable to abuse. Despite this, the facility did not recognize the resident's actions as abuse and failed to report them to the appropriate authorities. The lack of reporting and investigation prevented the facility from protecting the residents from further harm and addressing the behavior of the resident involved.
Failure to Screen Unlicensed Employees for Abuse and Neglect
Penalty
Summary
The facility failed to protect all 31 residents by not screening unlicensed employees prior to employment, which placed residents at risk for abuse, neglect, exploitation, and misappropriation of property. The facility's policy, revised in June 2023, mandates the screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes conducting background, reference, and credentials checks on potential employees, contracted temporary staff, students, volunteers, and consultants. However, the facility did not adhere to this policy, as evidenced by the administrator's admission that criminal history checks were not conducted on unlicensed employees or new hires. Instead of conducting thorough background checks, the facility relied on applicants' honesty regarding felony convictions on their application forms and community word-of-mouth in their small-town setting. The administrator acknowledged the lack of a system to screen non-licensed staff to ensure they have not been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This oversight in the facility's hiring process was identified during a survey, which reviewed the facility's CMS Matrix showing 31 residents and highlighted the deficiency in protecting residents from potential harm.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report incidents of resident-to-resident abuse to the Administrator and State Survey Agency (SSA) for three residents with cognitive impairments who were unable to consent. The facility's policy requires staff to notify their department supervisor immediately upon witnessing or having reliable knowledge of any act of abuse. However, this protocol was not followed in several instances involving residents with dementia and Alzheimer's disease. One incident involved a resident with dementia who was observed being touched and held by another resident, despite her family's explicit instructions against such contact. The family had initially consented to limited physical contact but later withdrew their consent due to the other resident's escalating behavior. The staff member who was informed of the family's wishes failed to recognize the situation as abuse and did not report it to the administrator. Another incident involved a resident with severe dementia who was observed kissing and touching other residents without their consent. Despite witnessing these actions, a nurse did not report the incidents to the Director of Nursing, administrator, or abuse coordinator, as required by the facility's policy. The administrative staff confirmed they were not notified of these behaviors, and the facility lacked evidence that the incidents were reported to the appropriate authorities.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of two residents, leading to deficiencies in care. For one resident with traumatic brain disorder and epilepsy, the care plan stated 'no water in room,' but did not specify the times when water should be provided or the reason for this restriction. Observations showed that the resident did not have a water cup in the room and had to request water, with staff indicating that water intake was restricted due to medication and obsessive-compulsive disorder. However, the care plan lacked details on the specific times and reasons for water restrictions, limiting staff's ability to ensure proper hydration management. Another resident with osteoarthritis had a care plan indicating the use of an EZ stand lift with one staff assist for transfers, but it failed to include the use of a buttocks sling and leg strap as per physician's orders. An observation revealed that a CNA transferred the resident without using the required equipment, which was not reflected in the care plan. An administrative nurse acknowledged the expectation for individualized care plans, highlighting the facility's failure to update the care plan to include necessary transfer equipment, potentially compromising the resident's safety during transfers.
Inadequate Assistance and Investigation in Resident Transfers
Penalty
Summary
The facility failed to provide adequate assistance during mechanical lift transfers for two residents, leading to potential risks of pain and discomfort. Resident #3, diagnosed with muscle weakness and arthritis, was observed being transferred using the EZ Way stand lift without proper use of the seat strap. The resident was unable to bear weight and hung from the chest harness, causing the harness straps to pull upward into the axillae, raising the shoulders to ear level. This improper use of the lift was observed on two separate occasions, with the CNA failing to position the seat strap correctly under the buttocks. Resident #10, diagnosed with dementia and osteoarthritis, was also transferred using the EZ Way stand lift without the application of the seat/buttocks and leg straps, as required by the physician's order. This oversight during the transfer process further exemplifies the facility's failure to adhere to proper procedures, potentially compromising the resident's safety and well-being. Additionally, the facility did not complete a thorough investigation for Resident #4, who had a history of falls and a recent fracture. Despite experiencing seven falls within a two-month period, including one with a major injury, the facility failed to update the care plan since 2020 and did not implement a corrective action plan. The administrative nurse confirmed the lack of a completed investigation and corrective measures, indicating a significant oversight in addressing the resident's fall risk and ensuring their safety.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a certified nurse aide (CNA #4) who did not adhere to proper hand hygiene and equipment disinfection protocols. During an observation, CNA #4 was seen transferring a resident using a sit-to-stand lift without cleaning or disinfecting the equipment between uses. Additionally, the CNA did not perform hand hygiene after removing soiled gloves and before touching clean items, such as the resident's blanket and sheets. The CNA acknowledged the failure to wash hands and change gloves appropriately during care. Another observation revealed that a different CNA (#8) also did not disinfect the sit-to-stand lift after assisting a resident to the bathroom. During an interview, CNA #8 stated that she does not clean the lift between uses, as she believed housekeeping was responsible for this task. The Director of Nursing (DON) confirmed that staff should wash their hands before and after resident care and clean equipment between each use to prevent infection spread.
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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