Sunset Drive - A Prospera Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Mandan, North Dakota.
- Location
- 1011 Boundary St Nw, Mandan, North Dakota 58554
- CMS Provider Number
- 355065
- Inspections on file
- 37
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Sunset Drive - A Prospera Community during CMS and state inspections, most recent first.
A resident with a history of wandering and identified elopement risk, who was cognitively intact and using a wander guard, followed a visitor out the front door when the door alarm sounded. The receptionist observed the resident leaving and notified a nurse, who then went to the front entrance, but during this delay the resident walked off the premises toward a nearby gas station. A CNA saw the resident walking in the street with a walker and later found the resident inside the gas station purchasing cigarettes, after which the resident was returned to the facility. Facility camera footage confirmed the time the resident left and returned, demonstrating that staff did not provide adequate supervision or timely response to the door alarm to prevent the elopement.
Two residents with histories of behavioral issues physically assaulted other residents, one after a wheelchair collision and another during a meal, resulting in physical abuse of residents with cognitive impairments. Both incidents were witnessed by staff and involved residents with documented behavioral risks.
Two residents requiring modified diets and direct or 1:1 supervision during meals were observed eating without the required staff supervision and with access to straws, despite physician orders and care plans specifying otherwise. Staff confirmed these orders were not followed during the observed mealtimes.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
Two residents dependent on staff for oral care did not consistently receive scheduled oral hygiene assistance as required by their care plans and facility policy. Documentation showed multiple missed instances of AM and PM oral care over several months, and an administrative staff member confirmed that staff were expected to provide this care as planned.
Multiple residents experienced significant delays in call light response, with some waiting from 25 minutes to over three hours for assistance. Observations, call light logs, and staff interviews confirmed that insufficient nursing staff led to unmet resident needs, including prolonged periods in soiled conditions and emotional distress, contrary to facility policy and expectations.
Staff did not administer medications within the required timeframe for multiple residents, with medications given more than one hour late on several occasions. The facility lacked a policy on timely medication administration, and an administrative nurse confirmed the expectation for medications to be given within one hour of the scheduled time.
A resident with quadriplegia and a right foot fracture was injured during van transport when staff failed to turn off the power to the individual's motorized wheelchair. While the van was moving, the resident accidentally activated the chair, causing it to move forward and the foot board to strike the chair in front, resulting in a foot injury.
The facility did not ensure accurate documentation and communication of advance directives for several residents. In one instance, a resident on comfort care was transferred to the ED with an incorrect POLST, and the error was only discovered after transfer. For four other residents, there was no documentation that code status discussions occurred with the residents or their representatives, despite physician orders being present. An administrative nurse confirmed that such discussions and documentation were expected but not completed.
Surveyors observed strong urine odors, dirty floors, stripped beds, dusty medical equipment, damaged furniture, and water-stained ceiling tiles affecting several residents. Staff interviews confirmed that maintenance requests for these issues were not documented as required by facility policy.
Several residents with diabetes and physician's orders for insulin did not have care plans updated to include monitoring and interventions for hypoglycemia and hyperglycemia, and a resident with a foot ulcer under enhanced barrier precautions lacked appropriate care plan documentation for EBP. An administrative nurse confirmed that staff did not update these care plans as required by facility policy.
Multiple residents requiring assistance with ADLs did not receive scheduled showers or baths as outlined in their care plans and physician orders, with some receiving only partial hygiene care or none at all. Residents reported feeling neglected and cited lack of staff as the reason for missed care, while staff interviews confirmed that scheduled hygiene services were not consistently provided. Documentation of care was inconsistent, and the facility could not provide a policy on bathing and personal hygiene.
Multiple residents reported that insufficient nursing staff led to long call light response times, missed showers, and delays in assistance, with some residents experiencing incontinence or waiting on the floor after a fall. Staff confirmed that bath aides were frequently reassigned, and other departments such as activities and dining were also short-staffed, resulting in unmet resident needs and complaints about cold food.
The facility did not ensure food was served at appetizing temperatures, as multiple residents reported receiving cold meals and staff failed to consistently monitor or record food temperatures. Dietary aides lacked education on temperature checks, and ongoing complaints were documented in resident council meetings, indicating a persistent issue with food not being served hot.
Staff did not consistently follow infection control standards, including Enhanced Barrier Precautions, during high-contact care for multiple residents with wounds, indwelling devices, or MDRO history. Lapses included not wearing gowns, improper glove use, inadequate hand hygiene, and failure to disinfect shared equipment and supplies after use.
Staff did not consistently place the call light within reach for a legally blind, non-ambulatory resident, leaving it on a chair at the foot of the bed after care was provided. The resident reported that staff frequently forgot to return the call light, despite her care plan specifying the need for accessible bedside items.
A resident with a guardian experienced a room change without receiving the required written notice or explanation, as confirmed by record review and staff interviews. Facility policy mandates that residents and their representatives be notified in writing before any room relocation, but this procedure was not followed.
A resident was observed with multiple medications and a tube of nystatin cream at the bedside without a completed assessment or physician's order for self-administration, as required by facility policy. An administrative nurse confirmed the omission of both the assessment and the order.
Two residents requiring assistance with personal hygiene experienced lapses in dignity when one was repeatedly observed with a soiled chest vest positioning device and visible residue on the face, while another was left exposed on the toilet with doors open and no staff present. Care plans for both residents indicated the need for staff assistance with these activities.
Two residents were unable to reliably access their personal food items stored in the facility's resident fridge. One resident's meals brought by family were reported missing when requested, and another resident faced barriers in accessing flavored coffee creamer due to staff availability and storage limitations. These actions did not support resident autonomy or choice as required.
Two residents with cognitive impairment were not adequately protected from potential sexual abuse when staff failed to follow care plan interventions and provide required supervision. One resident was found in another's room at night and admitted to kissing and holding hands, while another incident involved inappropriate physical contact in the dining room. Staff, including new dietary personnel, were unaware of necessary restrictions, leading to lapses in monitoring and supervision.
The facility did not report an incident involving two residents, where one entered another's room and engaged in physical contact, as potential abuse to the SSA, despite facility policy requiring such reporting.
A resident was hospitalized, and the facility did not provide the required written notice of transfer or bed-hold policy information to the resident, their representative, or the State Long Term Care Ombudsman, as mandated by facility policy.
A resident's required MDS assessments, including discharge, entry tracking, and significant change in status, were not transmitted to CMS within the mandated 14-day period. Multiple assessments were submitted several days late, as confirmed by record review and staff interview.
Staff failed to prime an insulin pen before administration for a resident, contrary to facility policy, and did not transcribe provider orders for continuous glucose monitoring for another resident. Additionally, lorazepam was administered to a resident without an active physician order after the previous order had expired.
Two residents who valued group and evening activities did not have access to scheduled evening programs, as activity calendars showed no such offerings and staff confirmed none were provided unless self-initiated. This was inconsistent with their care plans and documented preferences.
Staff did not implement restorative nursing and therapy services as outlined in the care plan for a resident with Parkinson's disease and severe contractures. The care plan required arm and leg exercises and the use of a stuffed animal in the hands, but observations showed no adaptive devices in place and staff interviews revealed a lack of awareness and documentation of the ROM program.
A resident with neuropathy, amputation, and chronic ulcers experienced ongoing severe pain due to the facility's failure to develop an effective pain management plan. The resident frequently required PRN oxycodone and reported inadequate relief from acetaminophen, yet the facility did not evaluate the pain regimen, notify the provider about frequent PRN use, or consider scheduled pain medications, resulting in unresolved pain and discomfort.
A resident did not have aspirin held as ordered by the physician before a scheduled surgery, due to inaccurate transcription and failure to follow the order. The medication was administered on days it should have been withheld, and this was confirmed by a nurse manager.
Surveyors found that cold food items, including milk and juice, were stored above the required temperature in a unit kitchenette, and staff were not educated on proper food storage procedures. In a separate incident, a CNA's thumb came into contact with a resident's sandwich, and the CNA wiped her thumb on her pants before delivering the food without hand hygiene.
The facility failed to protect residents from sexual abuse involving two residents with dementia. One resident was found engaging in inappropriate behaviors with another resident, while the second resident displayed inappropriate sexual behaviors towards others. Despite these incidents, the facility did not recognize or address these behaviors as abuse, failing to implement necessary interventions.
The facility failed to report incidents of resident-to-resident abuse involving two residents with dementia who exhibited inappropriate sexual behaviors. One resident was found in a female resident's room with her brief pulled down, and another resident was reported to have fondled another resident's private area. These incidents were not reported to the administrative staff or the SSA, contrary to the facility's policy.
A resident with a history of gastrointestinal issues experienced increased abdominal pain, tenderness, and vomiting, but the facility failed to notify the physician of these changes. Despite interventions, the resident's condition worsened, leading to death before an ER transfer could occur. The administrative nurse confirmed the failure to notify the medical provider, violating the facility's policy.
A facility failed to follow infection control standards for a resident with a suprapubic catheter. Staff did not wear gowns during high-contact care, despite the facility's policy requiring Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. The care plan and signage indicated the need for PPE, but staff only used gloves. An administrative nurse confirmed the expectation for proper PPE use during such care activities.
The facility failed to ensure call lights were within reach for several residents, as required by policy. Observations showed that call lights were placed out of reach for residents in various positions, including in bed, in a recliner, and in a wheelchair. This failure affected the residents' ability to call for assistance.
The facility failed to maintain the dignity and quality of life for two residents. A CNA left a resident's pants pulled down after incontinence care, which the resident confirmed happened frequently. Another resident was seen with an uncovered urinary catheter bag attached to their wheelchair, visible to others. These actions do not preserve personal dignity and may affect psychosocial well-being.
A resident in a LTC facility did not receive scheduled toileting assistance as outlined in her care plan, resulting in her being left in wet clothing for several hours. Observations and record reviews showed multiple instances of staff failing to perform checks and changes every 2-3 hours, as required. Interviews with administrative nurses confirmed that staff were expected to follow care plans, but this was not adhered to, leading to a deficiency in care.
The facility failed to promptly respond to call lights for two residents, leading to prolonged wait times. One resident, at risk for falls, had to move independently due to the delay. Call light logs showed response times far exceeding the facility's 15-minute goal, with one resident waiting over 33 minutes for assistance.
The facility failed to follow infection control standards during toileting assistance for three residents. CNAs did not perform hand hygiene after glove removal and before donning new gloves, contrary to the facility's policy. This included tasks such as cleansing perineal areas, adjusting clothing, and assisting with transfers, without adhering to proper hand hygiene protocols.
A resident with dementia was improperly restrained in a wheelchair with a sheet by an RN to prevent a fall, without proper documentation or assessment as required by the facility's policy. The incident was reported by a CNA, but no immediate action was taken until another CNA removed the restraint. The resident's care plan did not address the use of restraints, contributing to the deficiency.
The facility failed to ensure food was prepared and stored in a clean and sanitary manner in both the main kitchen and a kitchenette on Unit 2. Observations revealed soiled floors, moldy food items, and improperly labeled or expired food. The administrative dietary staff confirmed these issues, which have the potential to result in foodborne illness.
The facility failed to follow infection control standards for seven residents, including improper use of PPE, inadequate toileting care, and poor colostomy care. Staff did not adhere to the facility's policies, leading to potential infection risks.
The facility failed to notify the physician of a resident's low blood sugar readings, despite specific orders to do so. The resident, with type 2 diabetes, had two instances of low blood sugar (54 mg/dL and 53 mg/dL) where the physician was not informed, contrary to the facility's policy and the resident's care plan.
The facility failed to assess the use of a wheelchair lap belt as a possible restraint for a resident with a history of CVA, hemiplegia, aphasia, and apraxia. The medical record lacked evidence of ongoing assessment and evaluation of the lap belt since the initial order, and the care plan indicated the resident was unable to remove the belt. An administrative nurse confirmed the lack of a current evaluation, placing the resident at risk for unnecessary restraint and potential injury.
The facility failed to accurately code the MDS for three residents, incorrectly indicating they received hypnotic medication within the 7-day look-back period, despite medical records showing otherwise. An administrative staff member confirmed the expectation for accurate MDS coding.
The facility failed to follow professional standards for IV administrations, enteral tube feedings, and post-surgical care. An IV solution bag was not labeled for a resident, an enteral tube feeding container lacked necessary labeling, and a resident with a recent surgical incision experienced increased pain due to improper care.
The facility failed to follow physician's orders for PICC line care, resulting in improper dressing application and lack of catheter length measurement. Additionally, staff did not document a bruise observed on a resident, which was caused by striking a pipe during a transfer.
The facility failed to provide necessary care for a resident with a stage 3 pressure ulcer, as the required heel boot and dressing were not consistently applied according to physician's orders and the care plan.
The facility failed to ensure proper transfer procedures for two residents, leading to potential accident risks. One resident was transferred using an incorrect harness size, while another was assisted to stand from an unlocked wheelchair, causing it to roll backward.
A nurse left a medication/treatment cart unlocked, unattended, and not within view while delivering medications to residents. The facility's policy requires medications to be stored in a locked cart, which was confirmed by an administrative nurse.
Elopement Following Delayed Response to Door Alarm
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring to prevent an elopement when a cognitively intact resident exited the building and went to a gas station across the street. The resident had a BIMS score of 13 and a care plan dated the same day as the incident that identified potential for elopement related to wandering aimlessly, with use of a wander guard to alert staff of the resident’s movements. On the day of the incident, the resident followed a visitor out the front door. The front door alarm beeped twice and the light flashed, and the front desk receptionist observed the resident leaving and called a nurse on Unit 2 to ask if a resident wearing an orange jacket and hat was expected. The nurse then walked down to the front door and went outside. During this time, the resident continued off facility property and proceeded toward the gas station across the street. A CNA saw the resident walking on the street with a walker toward the gas station. By the time staff reached him, the resident was inside the gas station purchasing cigarettes. Camera footage showed the resident left the facility at 4:37 p.m. and returned at 4:48 p.m. Staff interviews indicated that a wander guard had been placed on the resident earlier that day after he exited a secured courtyard, but the resident was still able to leave the building and reach the gas station before staff intervened. The facility did not respond immediately to the door alarm in a manner that prevented the resident from eloping from the building and grounds.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents of resident-to-resident physical altercations. In the first incident, a resident with vascular dementia, psychotic and mood disturbances, and anxiety, who was noted to have behavioral symptoms and a history of being short-tempered, struck another resident in the face after a minor collision between their wheelchairs. The resident who was struck had diagnoses including anxiety and metabolic encephalopathy, which can cause confusion and memory loss. The altercation occurred after the aggressor yelled at the other resident to move away and then made physical contact when the request was not met quickly enough. In the second incident, a resident with a history of violent behavior and a care plan noting prior physical altercations slapped another resident on the upper arm while both were seated at a dining table. The resident who was slapped had severe cognitive impairment due to dementia and anxiety. The incident was witnessed by a dietary aide, and the aggressor was identified as having intact cognition. Both incidents demonstrate a failure to prevent resident-to-resident abuse, as required by facility policy.
Failure to Follow Physician Dietary Orders and Supervision Requirements During Meals
Penalty
Summary
Facility staff failed to follow professional standards of practice and physician orders for two residents requiring specific dietary modifications and supervision during meals. For one resident, physician orders and care plans specified a soft and bite-sized texture diet, thin liquids with no straw, and direct supervision during meals. Observations showed the resident had access to beverages with straws and consumed meals without staff supervision, contrary to the prescribed orders. Supervisory staff confirmed these requirements were not met during the observed mealtime. For another resident, physician orders and care plans required a minced and moist texture diet, thin liquids with no straw, and 1:1 supervision during meals. The resident's meal ticket also indicated the need for 1:1 supervision. However, during observation, the resident was seen eating at a dining room table with no staff present to provide the required supervision. An administrative dietary staff member confirmed that staff presence was expected for this resident during meals, as per the dietary orders.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Provide Scheduled Oral Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral hygiene services to two residents who were dependent on staff for oral care. According to the facility's policy, residents unable to perform activities of daily living (ADLs), including oral hygiene, should receive assistance to maintain personal hygiene. Record review showed that one resident required assistance of one staff member for oral care every morning and at bedtime, with an increased frequency scheduled in July. Documentation revealed multiple instances where scheduled oral care was not completed, including missed AM and PM care over several days in May, June, and July, and no night or PRN oral care documented in July. A second resident, who required set-up assistance for oral care twice daily, also had missed AM and PM oral care on several days in July. During staff interviews, an administrative staff member confirmed the expectation that staff provide oral care as outlined in the care plans. The findings were based on review of facility policy, medical records, and staff interviews, demonstrating a failure to ensure that dependent residents received the necessary services to maintain oral hygiene.
Delayed Call Light Response Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents who required staff assistance, as evidenced by multiple instances of delayed responses to call lights. Observations and call light logs showed that several residents waited between 25 minutes to over three hours for staff to respond after activating their call lights. For example, one resident's call light was activated at 7:52 p.m. and staff responded one hour and 30 minutes later, while another resident waited over three hours for assistance. These delays were confirmed by both direct observation and review of facility call light logs. A confidential staff member reported being consistently short-staffed, resulting in residents crying and remaining in soiled conditions due to the lack of timely assistance. An administrative staff member stated that the expectation was for call lights to be answered within 15-20 minutes, which was not met in these cases. The facility's own policy and assessment indicated that adequate staffing should be provided to ensure resident safety and well-being, but the documented delays and staff interviews demonstrated that this standard was not maintained for several residents.
Failure to Administer Medications Timely per Professional Standards
Penalty
Summary
The facility failed to follow professional standards of practice for timely medication administration for all seven sampled residents. Record review showed that staff administered medications more than one hour late on multiple occasions for each resident, with some residents experiencing late administration up to ten times within the review period. The facility was unable to provide a policy regarding timely medication administration. Reference to professional nursing standards indicated that non-time-critical medications should be administered within one hour before or after the scheduled time. An administrative nurse confirmed the expectation that medications be administered within this timeframe.
Failure to Turn Off Power to Motorized Wheelchair During Transport Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that the power control to a resident's motorized wheelchair was turned off during van transport. The resident, who had diagnoses including quadriplegia, immobility, and a right foot fracture, was seated in a motorized scooter that was locked and secured with seat belts. However, the power to the scooter remained on, and while the van was in motion, the resident accidentally activated the forward button, causing the chair to move forward. This movement resulted in the scooter's foot board striking the chair in front, which then caused injury to the resident's right foot. The incident was identified when the resident reported pain in his right foot upon arrival at a clinic, leading to an x-ray that showed a healing fracture in the first metatarsal head. The facility's investigation confirmed that the van driver did not turn off the power to the motorized wheelchair before transport, which directly led to the accident and injury.
Failure to Accurately Document and Communicate Residents' Advance Directives
Penalty
Summary
The facility failed to ensure that residents' code status and advance directive wishes were accurately documented and communicated in the medical records for five residents. In one case, a resident who was on palliative care with a POLST indicating comfort measures only was transferred to the emergency department, and the incorrect POLST was sent with the resident. The error was only identified after the transfer, and the emergency department was notified of the mistake. Progress notes and interviews confirmed that the resident's updated POLST had been completed months prior, but the documentation and communication did not reflect the resident's current wishes at the time of the transfer. For four additional residents, the medical records contained physician orders regarding advance directives (either DNR or CPR), but there was no documentation that the facility had discussed code status with the residents or their representatives. In one case, the resident was not capable of making their own decisions and had a guardian, but there was still no evidence of discussion or documentation. An administrative nurse confirmed that staff are expected to discuss and document code status at admission and care conferences, but acknowledged that the required documentation was missing in these cases.
Failure to Maintain Safe, Clean, and Homelike Environment for Multiple Residents
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, comfortable, and homelike environment for several residents. Observations included strong urine odors in two residents' rooms, a sticky bathroom floor, a resident's bed stripped of all linens on two occasions, and a dirty floor with stains and debris. Additionally, an oxygen concentrator was found covered with dust, including the air intake and filter area, and wallpaper was missing or torn behind a resident's headboard, with dried food particles present on the floor. Another resident's overbed table had cracked, raised, and peeling laminate, and water stains were observed on ceiling tiles above the bed. Interviews with staff revealed that maintenance requests for these issues were not documented in the facility's maintenance binder, despite facility policy requiring immediate reporting of such concerns. Staff confirmed the poor condition of the overbed table and the presence of ceiling tile stains, as well as the lack of maintenance requests for the damaged wallpaper and other environmental deficiencies.
Failure to Update and Revise Care Plans for Residents with Diabetes and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of several residents. Specifically, for six sampled residents and one supplemental resident with diagnoses including diabetes and physician's orders for insulin, care plans did not include monitoring for signs and symptoms of hypoglycemia and hyperglycemia, nor did they outline interventions to address these conditions. Additionally, one resident with a foot ulcer and enhanced barrier precautions (EBP) in place did not have EBP addressed in their care plan with appropriate problems, goals, or interventions. These omissions were confirmed by an administrative nurse during staff interviews and were not in accordance with the facility's policy requiring individualized, comprehensive care plans.
Failure to Provide Scheduled Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that several residents who required assistance with activities of daily living, specifically bathing and personal hygiene, received the necessary services. Observations and record reviews revealed that multiple residents did not receive scheduled showers or baths as outlined in their care plans and physician orders. For example, one resident was observed with long, dirty fingernails, and their records showed they received only one of four scheduled showers and one bed bath over a two-week period. Another resident, diagnosed with seborrheic dermatitis, received only three of eight scheduled baths in one month and two of four in the following two weeks, and reported not having a bath in over a week, feeling neglected, and experiencing worsening scalp conditions due to missed showers. Additional residents with conditions such as candidiasis, eczema, and severe dry skin also did not receive the required number of showers, with one resident receiving only half of the physician-ordered showers and no bed baths or refusals documented. Residents reported being told that showers could not be provided due to lack of staff or bath aides, and some expressed dissatisfaction with sponge baths as a substitute for showers. Another resident stated that a family member had to provide a shower due to missed scheduled baths, and voiced concerns about future missed hygiene care due to ongoing staffing shortages. Staff interviews confirmed that scheduled baths and showers were not consistently provided, often due to insufficient staffing. There was also confusion among staff regarding the difference between sponge baths and bed baths, with some staff indicating that sponge baths involved minimal assistance and did not constitute full body hygiene care. The facility was unable to provide a policy regarding bathing and personal hygiene, and documentation often conflicted with resident statements about care received.
Failure to Provide Sufficient Nursing Staff and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff and related services to meet the needs of residents, as evidenced by multiple complaints and observations documented in resident council meeting minutes, confidential resident interviews, and staff interviews. Residents reported that call lights were frequently turned off by CNAs without their needs being met, and that response times to call lights were lengthy, sometimes taking up to an hour. Several residents stated they missed scheduled showers due to staffing shortages, with some relying on family members for personal care. One resident described waiting approximately 40 minutes for assistance and experiencing incontinence as a result, while another reported lying on the floor for about 20 minutes after a fall before help arrived. Staff interviews corroborated these concerns, indicating that bath aides were often reassigned to other duties, resulting in residents not receiving scheduled baths. The activity department and dining services were also reported to be understaffed, leading to delays and cold food being served. These findings affected at least seven residents who required staff assistance, and the issues persisted over several months, as reflected in repeated complaints during resident council meetings.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable and appetizing temperatures across all four units, as evidenced by observations, policy review, resident council meeting minutes, and multiple resident and staff interviews. Residents consistently reported receiving cold food, with some stating that trays were set down before they could eat, resulting in the food cooling further. Several residents expressed reluctance to request reheating due to staff shortages or infection control restrictions. Resident council meeting minutes over several months documented ongoing complaints about cold food, with residents requesting solutions such as hot plates and staff education. Observations revealed that dietary staff did not consistently monitor or record food temperatures before serving, and there was a lack of education regarding when and how to take food temperatures. Dietary aides transported food on open carts and failed to use proper temperature monitoring practices, while dietary managers acknowledged that test tray quality assurance checks regarding food temperature and palatability had not been completed. These actions and inactions led to the deficiency of not providing food at safe and appetizing temperatures for residents.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to established infection prevention and control standards for 9 of 10 sampled residents during care activities. Observations revealed that staff did not consistently follow Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care for residents with indwelling devices, wounds, or a history of multidrug-resistant organisms. In multiple instances, staff performed hand hygiene and donned gloves but neglected to wear gowns as required by EBP policy. For example, during catheter care and wound dressing changes, staff either omitted the gown or applied it incorrectly, and in some cases, failed to change gloves or perform hand hygiene between tasks or after glove removal. Staff also failed to properly disinfect shared equipment such as mechanical lifts after use, as observed when lifts were moved from resident rooms to hallways without cleaning. Additionally, there were lapses in hand hygiene practices, with staff not performing hand hygiene after glove removal, after handling soiled items, or before handling clean items. In several cases, staff changed gloves between tasks without washing or sanitizing their hands, and sometimes handled clean supplies or resident personal items with contaminated gloves. The report further documents failures in following specific infection control procedures during catheter care, such as not cleaning catheter connection sites with alcohol before connecting new tubing. Supplies used for wound care and insulin administration were not always sanitized before being returned to common storage areas. These deficiencies were confirmed through observation, record review, and staff interviews, with administrative staff acknowledging the expectation for proper hand hygiene, PPE use, and equipment disinfection.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
Facility staff failed to ensure that a resident's call light was consistently placed within reach, as required by facility policy. Observations on two separate occasions found the call light on a chair at the foot of the bed, out of the resident's reach, while the resident was in bed. The resident, who is legally blind and non-ambulatory, reported that staff routinely moved the call light to the chair and forgot to return it to her after providing care. The resident's care plan specifically noted the need to describe the location of items at bedside due to her visual impairment.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to provide written notice of a room change to a resident and the resident's guardian, as required by facility policy. Record review showed that the resident, who has a guardian to assist with care decisions, experienced a room change, but there was no evidence in the medical record that written notification or an explanation for the move was given to the resident or the guardian. Staff interviews confirmed that the required written notice was not present in the resident's record. The facility policy states that residents and/or their representatives must receive written notice, including the reason for the change, prior to any room relocation, and be given an opportunity to discuss and ask questions about the move.
Failure to Assess and Obtain Order for Self-Administration of Medications
Penalty
Summary
The facility failed to complete an assessment and obtain a physician's order for a resident to self-administer medications, as required by facility policy. Observation revealed that the resident had two paper medication cups containing several pills and a tube of nystatin cream at the bedside. Review of the resident's medical record showed no documentation of a self-administration assessment or a physician's order authorizing self-administration of medications. An administrative nurse confirmed that the necessary assessment and order were not completed for this resident.
Failure to Maintain Resident Dignity During Personal Hygiene and Toileting
Penalty
Summary
The facility failed to maintain or enhance the dignity of two residents who required assistance with personal hygiene. For one resident, repeated observations over several days showed the individual seated in a wheelchair with a chest vest positioning device that was soiled with debris, and on one occasion, a white substance was noted on the left side of the resident's mouth and chin. The resident's care plan indicated a need for assistance with dressing, repositioning, and personal hygiene. For another resident, an observation revealed that both the room and bathroom doors were left open while the resident was seated on the toilet and visible from the hallway, with no staff present, despite the care plan indicating the need for assistance with toileting. An administrative nurse confirmed that staff are expected to keep doors closed during resident care.
Failure to Honor Resident Choice for Personal Food Items
Penalty
Summary
The facility failed to honor resident choices regarding access to personal food items stored in the resident fridge for two sampled residents. One resident reported that food brought in by her son was lost or discarded by the facility. Upon inspection, several of her meals were found in the resident food fridge, properly labeled and dated. However, when the resident requested a specific meal, staff initially told her it was missing. The meal was later found and offered to her, but she refused it at that time. This sequence of events demonstrates a failure to ensure timely and reliable access to personal food items as requested by the resident. Another resident experienced difficulty accessing personally purchased flavored coffee creamer stored in the resident food fridge. The resident expressed that nursing staff were too busy to retrieve the creamer from the kitchen and requested that it be stored in a more accessible location. Staff suggested purchasing individual creamers to keep in his room, but the resident stated these were too expensive. Staff confirmed that the creamer should be stored in the resident food fridge and delivered upon request, but the resident's concerns about access were not resolved. These incidents show the facility did not consistently support or facilitate resident self-determination and choice regarding personal food items.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents with impaired cognition from potential sexual abuse by not ensuring adequate supervision and adherence to care plan interventions. One incident involved a resident with dementia and behavioral disturbances being found with another cognitively impaired resident in her room late at night, where the male resident admitted to kissing and holding hands with her. The female resident, who was not to be left alone with male residents due to her cognitive status and lack of safety awareness, was found awake with her knees elevated, and could not recall the incident when later questioned. The male resident had a documented history of wandering into female residents' rooms and displaying physical affection, with a behavior contract and specific monitoring interventions in place, including door alarms and staff supervision requirements. Despite these interventions, staff failed to consistently monitor the whereabouts of both residents and did not prevent unsupervised contact. Another incident occurred in the dining room, where the male resident was observed sitting next to the female resident and placing his hand on her knee, despite care plan instructions that he should not be within five feet of female residents without supervision. New dietary staff were unaware of these restrictions, further contributing to the failure to protect residents from potential abuse. The facility's lack of effective supervision and failure to implement care plan interventions resulted in residents not being free from potential sexual abuse.
Failure to Report Potential Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report incidents of potential abuse involving two residents who displayed sexual behaviors towards each other to the State Survey Agency (SSA), as required by facility policy. According to the policy, all incidents and results of investigations must be reported to the SSA within five working days. Record review showed that one resident could not recall the incident when questioned, while the other admitted to entering a female resident's room, holding her hand, and kissing her. Despite these documented events, the facility did not report the incident as potential abuse to the SSA.
Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalization
Penalty
Summary
The facility failed to provide a written notice of transfer and a bed-hold notice to a resident and their representative, as well as to the State Long Term Care Ombudsman, when the resident was hospitalized from January 30, 2025 through February 2, 2025. Record review showed that the facility's policies required written notification to the resident, their representative, and the Ombudsman prior to transfer, and that information about the bed-hold policy must be given at the time of transfer. However, documentation confirming that these notifications were completed was not found in the resident's medical record for the hospitalization event.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to ensure timely electronic submission of required Minimum Data Set (MDS) assessments for one resident, as mandated by federal regulations and outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. Specifically, the facility did not transmit several MDS assessments to the Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) within the required 14-day timeframe. The late submissions included a discharge return anticipated MDS transmitted 4 days late, another discharge return anticipated MDS transmitted 3 days late, an entry tracking MDS transmitted 18 days late, and a significant change in status MDS transmitted 3 days late. These findings were confirmed through record review, staff interviews, and examination of the federal database for long-term care surveys. An administrative nurse acknowledged during an interview that the MDS assessments for the resident in question were transmitted after the required deadlines, confirming the facility's noncompliance with timely data submission requirements.
Failure to Follow Professional Standards in Medication Administration and Order Transcription
Penalty
Summary
Facility staff failed to follow professional standards of practice during insulin administration for a resident. Observation showed a nurse preparing an insulin pen for a resident without priming the pen as required by facility policy. When questioned, the nurse stated she never primes insulin pens. An administrative nurse confirmed that staff are expected to prime insulin pens before administering the prescribed dose. Additionally, the facility did not provide care in accordance with professional standards for two residents. For one resident, provider orders regarding the use of a continuous glucose monitoring system were not transcribed into the electronic health record, including the medication administration record and care plan. For another resident with an anxiety disorder, a nurse administered lorazepam without an active physician order, as the previous order had expired. An administrative nurse confirmed the medication was given without a current order.
Failure to Provide Scheduled Evening Activities to Meet Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities designed to meet the interests and preferences of residents, as required by policy. Record review and interviews revealed that for at least two residents, their care plans and comprehensive assessments identified participation in favorite and group activities, including evening games and going outside, as very important. However, the activity calendars from March through May showed no scheduled evening activities, and residents reported that such activities were only available if self-initiated with other residents. Interviews with residents confirmed dissatisfaction with the lack of organized evening activities, with one resident specifically expressing a desire for more structured games like Yahtzee and cards in the evenings. An activity staff member also confirmed that no scheduled evening activities had been provided in the past three months unless initiated by residents themselves. This lack of scheduled activities did not align with the residents' documented preferences and care plan goals.
Failure to Provide Restorative Services for Resident with Contractures
Penalty
Summary
Staff failed to provide restorative nursing and therapy services as outlined in the care plan for a resident with Parkinson's disease and severe contractures. The resident's care plan specified the need for restorative interventions, including arm and leg exercises on both sides and the use of a stuffed animal in the hands to address contractures. However, observations over multiple days revealed that the resident's hands were severely contracted in a gripping position, arms were tight to the chest, and feet were pointed downward, with no adaptive devices or stuffed animals in place as required by the care plan. Interviews with multiple CNAs indicated a lack of awareness and implementation of the resident's ROM program. One CNA stated that ROM exercises should be performed by the bath aide as noted in the white binder, but confirmed she was not aware of any ROM program for the resident. Review of the white binder showed no documentation of ROM exercises for the resident. Additional CNAs reported significant difficulty in cleaning the resident's hands due to contractures and noted very limited arm mobility, with one CNA suggesting possible skin breakdown in the inner hands. These findings confirm that staff did not implement the planned interventions for contractures.
Failure to Develop and Implement Effective Pain Management Plan
Penalty
Summary
The facility failed to develop and implement an effective pain management regimen for a resident with significant pain-related diagnoses, including neuropathy, above-the-knee amputation, and chronic foot ulcers. The resident's care plan identified acute pain and set a goal for adequate pain relief, but the pain management approach relied heavily on as-needed (PRN) medications rather than scheduled dosing. The resident reported persistent, severe pain and expressed dissatisfaction with the effectiveness of acetaminophen, preferring oxycodone and wishing it was scheduled to avoid having to request it repeatedly. Observations during care activities, such as dressing changes, showed visible signs of pain, including grimacing and movement of the affected limb, with the resident rating pain as high as 8 out of 10 and frequently requesting pain medication. Review of the resident's medical record and medication administration records revealed frequent use of PRN oxycodone (67 times) and acetaminophen (8 times) over a short period, indicating ongoing, unresolved pain. Despite these frequent requests and high pain ratings documented in assessments and interviews, the facility did not adequately evaluate the effectiveness of the current pain management plan, failed to notify the provider about the frequent PRN use, and did not consider transitioning to scheduled pain medications. This lack of proactive pain management resulted in the resident experiencing ongoing pain and discomfort.
Failure to Hold Medication Prior to Surgery
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff did not hold aspirin as ordered by the physician prior to a scheduled surgery. The physician's order specified that aspirin should be held five days before the procedure, but review of the medication administration record showed that the medication was administered on three days when it should have been withheld. This error was due to inaccurate transcription and failure to follow the physician's order, as confirmed by a nurse manager during an interview.
Improper Food Storage and Unsanitary Food Handling Observed
Penalty
Summary
Surveyors observed that food items in the Grandview Unit Kitchenette were not stored at proper temperatures after meal service. Specifically, a half gallon of milk and cranberry juice in the cold well measured 46.8 degrees Fahrenheit, exceeding the facility's policy requirement for cold food to be held at less than 41 degrees Fahrenheit. The cold well itself had a temperature of 52 degrees Fahrenheit and showed significant frost buildup. Staff interviews revealed that dietary aides were not educated on returning items to the refrigerator after meal service, and the items were left in the cold well instead. Additionally, during meal service on the Sunset Unit, a CNA's thumb accidentally touched a resident's jelly sandwich. The CNA wiped the food debris from her thumb onto her pants and then proceeded to deliver the sandwich to the resident without changing gloves or washing hands. This incident was observed and brought to the CNA's attention by a survey team member.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically sexual abuse, involving two residents with dementia. Resident #1, who had mild cognitive impairment, was documented to have inappropriate sexual behaviors, including entering a vulnerable female resident's room and engaging in inappropriate physical behaviors. On multiple occasions, Resident #1 was found in Resident #2's room, with incidents involving inappropriate touching and undressing. Despite these occurrences, the facility did not recognize these behaviors as sexual abuse and failed to implement interventions to prevent them. Resident #2, who had severe cognitive impairment, also displayed inappropriate sexual behaviors towards other residents and staff. Incidents included fondling another resident and touching a CNA inappropriately. Staff interviews revealed that Resident #2 was known to be 'touchy/feely' and attempted to engage male residents inappropriately. Despite these behaviors being known, the facility did not take adequate steps to address or report these incidents, leading to a failure in protecting residents from abuse.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report incidents of resident-to-resident abuse to the administrator and State Survey Agency (SSA) for two residents who exhibited sexual behaviors. The facility's policy, revised in July 2024, mandates that all identified incidents of alleged or suspected abuse or neglect are promptly reported and investigated. However, the facility did not adhere to this policy, as evidenced by the incidents involving two residents with dementia who displayed inappropriate sexual behaviors towards other residents. Resident #1, diagnosed with dementia and identified with mild cognitive impairment, was noted in the care plan to have behavior symptoms related to inappropriate sexual advances. An incident on November 6, 2024, involved Resident #1 being found in a female resident's room with her brief pulled down. Similarly, Resident #2, also diagnosed with dementia and severe cognitive impairment, was reported to have fondled another resident's private area on October 26, 2024. On November 5, 2024, a CNA reported seeing Resident #1 lifting Resident #2's shirt. These incidents were not reported to the administrative staff, and consequently, were not reported to the SSA, as confirmed by an administrative nurse during an interview.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, which is a violation of the facility's policy on Notification of Change. The policy requires immediate consultation with the resident's physician and notification of the resident's representative when there is a significant change in the resident's physical status or a need to alter treatment. In this case, the resident, who had a history of gastrointestinal issues, experienced increased abdominal pain, tenderness, rigidity, and vomiting, but the physician was not informed of these changes. The resident's medical record indicated a history of gastroesophageal reflux disease, gastrointestinal hemorrhage, and peptic ulcer. The care plan included monitoring for complications related to constipation, such as a swollen abdomen and vomiting. Despite these instructions, the resident's condition worsened over a period of two days, with documented complaints of abdominal pain and constipation, and the administration of medications like Milk of Magnesia and Tramadol. However, these interventions were noted to be ineffective, and the resident's condition continued to deteriorate. On the morning of the resident's death, the resident reported increased abdominal pain and dry heaving, and expressed a desire to go to the emergency room. The facility obtained consent from the resident's power of attorney to send the resident to the ER, but before the transfer could occur, the resident's condition rapidly declined, resulting in death. The administrative nurse confirmed that the staff failed to notify the resident's medical provider of the change in condition, which may have impacted the care provided to the resident.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for a resident with an indwelling suprapubic catheter. The facility's policy on Enhanced Barrier Precautions (EBP) requires staff to wear personal protective equipment (PPE), including gowns and gloves, during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms. This policy applies to residents with indwelling medical devices, such as urinary catheters. Despite these guidelines, staff did not wear gowns while providing high-contact care to the resident, which included transferring the resident using a mechanical lift and providing incontinent care. During the survey, it was observed that two nurses and two CNAs entered the resident's room to provide care without wearing the required gowns, although gloves were used. The resident's care plan and a sign on the door indicated the need for EBP, including the use of gowns and gloves. An administrative nurse confirmed the expectation for staff to wear appropriate PPE during high-contact care activities for residents on EBP. The failure to comply with these precautions has the potential to spread infection throughout the facility.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs regarding call lights for five of ten sampled residents. Observations revealed that call lights were not placed within reach of the residents, contrary to the facility's policy. Specifically, one resident was found resting in bed with the call light on the overbed table, out of reach. Another resident was asleep in bed with the call light hanging from the bottom rung of the bed rail, also out of reach. A third resident was asleep with the call light on the bedside table, inaccessible. Additionally, a resident seated in a recliner had the call light across the room, wrapped around the bed rail and covered with bedding. Lastly, a resident in a wheelchair was unable to locate her call light, which was wrapped around the bed rail behind her, and remained without access to it during subsequent observations.
Failure to Maintain Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to provide care that promotes, maintains, or enhances the quality of life for two residents. For one resident, a certified nurse aide (CNA) was observed providing incontinence care and leaving the resident's pants pulled down below the brief, which the resident confirmed happened frequently. The resident expressed a desire to be dressed properly, indicating a lack of dignified care. Another resident was observed independently moving through the hallways in a powered wheelchair with an uncovered urinary catheter bag attached to the back, visible to other residents and visitors. This lack of coverage for the catheter bag does not preserve the resident's personal dignity and has the potential to affect their psychosocial well-being.
Failure to Provide Scheduled Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance for a resident, leading to a deficiency in care. The resident, who was unaware of when she was wet or soiled, required regular checks and changes every 2-3 hours as per her care plan. However, observations on the day of the survey revealed that the resident was left in a wheelchair for several hours without being toileted, resulting in her pants being visibly wet with urine. The resident reported not being toileted since breakfast, and staff failed to assist her before taking her to the dining room for lunch. Further review of the resident's toileting record showed multiple instances where staff did not perform the required checks and changes every three hours, with gaps ranging from 3.5 to 7 hours. The care sheets, which were supposed to guide the CNAs in providing care, indicated the need for regular toileting assistance, but these instructions were not followed. Interviews with administrative nurses confirmed the expectation for staff to adhere to the care plans, highlighting a lapse in the facility's adherence to its own care protocols.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to promptly respond to residents' call lights, as observed in the cases of two residents. Resident #8, who has a self-care performance deficit related to deconditioning and is at risk for falls, was observed seated in her room after using her front wheeled walker to return from the bathroom without assistance. She confirmed that her call light had been on, but no staff responded, prompting her to move independently. Resident #8 reported that it often takes a while for staff to answer her call light, and she expressed a willingness to go to the bathroom by herself if staff are not available. On another occasion, both Resident #1 and Resident #8's call lights were observed flashing in the hallway, and it took approximately 35 minutes for an unidentified CNA to respond. During an interview, an administrative nurse stated that the expectation is for all staff to answer call lights within 15 minutes. However, the review of call light logs showed that Resident #1's call light was answered nearly 30 minutes after activation, and Resident #8's call light was answered over 33 minutes later. This delay in response time indicates a failure to meet the facility's policy and expectations for prompt assistance.
Inadequate Hand Hygiene Practices During Toileting Assistance
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding hand hygiene practices, during toileting assistance for three residents. Observations revealed that two CNAs did not perform hand hygiene after glove removal and before donning new gloves while assisting Resident #2. The CNAs completed various tasks, including cleansing the perineal area, adjusting clothing, and transferring the resident without performing hand hygiene, which is against the facility's policy. Similarly, another CNA failed to perform hand hygiene after assisting Residents #9 and #10 with toileting cares. The CNA did not change gloves between tasks and did not offer or provide hand hygiene to the residents after toileting. This CNA also engaged in additional activities, such as combing hair and providing water, without performing hand hygiene. These actions were contrary to the facility's hand hygiene policy, which requires hand hygiene after glove removal and before engaging in new tasks.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints imposed for convenience, affecting one of the two sampled residents reviewed for restraints. The incident involved a resident with dementia, who was found secured in a wheelchair with a sheet tied around her waist by a registered nurse. This action was taken to prevent a fall, as the resident was COVID positive and considered a high fall risk. However, the use of the sheet as a restraint was not documented or assessed as required by the facility's policy. The facility's policy on restraints clearly states that residents should be free from any physical restraints unless required to treat medical symptoms. The policy also requires documentation and assessment before applying any non-emergency physical restraint. In this case, the resident's medical record lacked documentation of observations suggesting the need for a restraint, an assessment of the restraint, and an order for its use. Additionally, the current care plan did not address the use of a restraint, indicating a failure to follow the established procedures. The incident was initially reported by a certified nurse aide who witnessed the restraint and confronted the nurse, but no immediate changes were made. Another CNA later removed the sheet and put the resident to bed. The facility's failure to document and assess the use of the restraint, as well as the lack of a care plan addressing the restraint, contributed to the deficiency. This oversight placed the resident at risk for unnecessary restraint and potential injury.
Failure to Maintain Sanitary Food Preparation and Storage Areas
Penalty
Summary
The facility failed to ensure food was prepared and stored in a clean and sanitary manner in both the main kitchen and a kitchenette on Unit 2. Observations revealed multiple issues including soiled floors and baseboards, moldy food items, and improperly labeled or expired food. Specifically, the main kitchen had moldy biscuits, a soiled food prep sink, and spiderwebs in the dry food storage area. The walk-in cooler contained expired tuna and dusty food storage racks, while the walk-in freezer had expired and undated food items with ice crystal build-up. Additionally, the residents' food refrigerator contained moldy raspberries, shriveled blueberries, and undated containers of unknown food items. The kitchenette on Unit 2 had lime scale on the ice and water machine and coffee machine. During an interview, the administrative dietary staff member confirmed that staff failed to discard expired foods from the resident refrigerator, clean surfaces and floors in the main kitchen, and clean the machines in the kitchenette on Unit 2. These failures have the potential to result in foodborne illness to residents, visitors, and staff. The facility's policies on food supply storage, date marking, food handling, and safe handling of personal food were not adhered to, contributing to the unsanitary conditions observed by the surveyors.
Infection Control and Care Deficiencies
Penalty
Summary
The facility failed to follow standards of infection control for seven residents during various care activities. Observations revealed that staff did not properly use personal protective equipment (PPE) in rooms where residents were placed in droplet isolation. For instance, two CNAs entered a resident's room without face shields and N95 masks, another CNA donned a gown without fastening the belt and wore an N95 mask over a surgical mask, and a third CNA collected a lunch tray without wearing an N95 mask and face shield. These actions were contrary to the facility's policy on PPE usage, which was revised in December 2023. Additionally, the facility failed to perform proper toileting and colostomy care. CNAs did not cleanse the frontal perineal area of two male residents after toileting, and one CNA used a non-cleanable pillow to protect a resident's skin during a transfer, which was then placed back on the bed. Another CNA performed colostomy care without changing gloves after handling a colostomy bag filled with stool, thereby failing to maintain hand hygiene. These deficiencies were confirmed by administrative nurses during interviews.
Failure to Notify Physician of Low Blood Sugar Readings
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who experienced low blood sugars. The resident, diagnosed with type 2 diabetes, had specific orders to notify the provider if blood sugar levels fell below 60 mg/dL. Despite this, the medical record showed two instances of low blood sugar readings (54 mg/dL and 53 mg/dL) where the physician was not notified. The facility's policy required immediate consultation with the resident's physician in the event of a significant change in the resident's physical status, which was not followed in this case. A progress note indicated that the resident had an episode of hypoglycemia and was treated with orange juice and glutose, resulting in a blood sugar level of 113 mg/dL. However, there was no documentation showing that the physician was informed of these low readings. An administrative nurse confirmed during an interview that the facility staff failed to notify the physician of the two low blood sugar readings, which was a deviation from the facility's policy and the resident's care plan.
Failure to Assess Wheelchair Lap Belt as Possible Restraint
Penalty
Summary
The facility failed to assess the use of a wheelchair lap belt as a possible restraint for a resident with a history of CVA, hemiplegia, aphasia, and apraxia. The resident was observed seated in a wheelchair with a lap belt in place, but the medical record lacked evidence of ongoing assessment and evaluation of the lap belt as a possible restraint since the initial order dated 12/13/21. The care plan indicated that the resident was unable to remove the belt and was aware of its presence but could not physically click or unclick it. The facility's policy required a licensed nurse to determine whether a device could be a restraint and to document the resident's response and ongoing re-evaluation of the need for the restraint. However, the medical record did not contain a current or recent evaluation of the lap belt, and an administrative nurse confirmed this during an interview. This failure placed the resident at risk for an unnecessary restraint and potential injury related to its use.
Inaccurate MDS Coding for Hypnotic Medication
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents. Specifically, the quarterly MDS for Resident #12, Resident #25, and Resident #40 incorrectly indicated that each resident received a hypnotic medication within the 7-day look-back period. However, a review of their medical records showed no documentation that these residents received such medication during that time frame. This discrepancy was confirmed by an administrative staff member during an interview, who acknowledged the expectation for accurate MDS coding.
Failure to Follow Professional Standards for IV Administration, Enteral Tube Feedings, and Post-Surgical Care
Penalty
Summary
The facility failed to follow professional standards for intravenous (IV) administrations for Resident #316. The IV solution bags were not labeled with the resident's name, date, and time, as required by the facility's policy. This was confirmed by an administrative nurse during an interview. The lack of labeling could lead to medication errors and adverse reactions, as the staff did not adhere to the established protocol for IV administration. Additionally, the facility did not follow professional standards for enteral tube feedings for Resident #77. The enteral tube feeding container was not labeled with the resident's name, date, time, and nurse's initials, contrary to the facility's policy. This was observed during a medication administration, and the nurse on duty could not confirm when the formula was started. Furthermore, the facility failed to provide necessary care for Resident #414, who had a recent surgical incision. The ACE wrap around the resident's chest incision was not removed as per the physician's order, causing increased pain and discomfort for the resident. An administrative nurse confirmed that staff did not follow the physician's orders regarding the dressing change.
Failure to Follow PICC Line Care and Document Skin Impairment
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a PICC line. During an observation, a nurse was seen administering IV antibiotics to a resident whose PICC line dressing was missing. The site appeared reddened and slightly swollen, and the resident reported soreness and discomfort. The nurse did not measure the catheter length and applied the dressing incorrectly. A nurse supervisor confirmed that staff are expected to follow physician's orders for PICC line care, which was not done in this instance. Additionally, the facility failed to report and document a bruise observed on another resident. A CNA noticed a bruise on the resident's upper left shoulder, which was caused by the resident striking a pipe during a transfer. A medication aide later confirmed the presence of the bruise, but the resident's medical record lacked documentation of this skin impairment. An administrative nurse confirmed that staff are expected to document such findings, which was not done in this case.
Failure to Implement Pressure Ulcer Care
Penalty
Summary
The facility failed to provide the necessary care and services to minimize the potential for the worsening of pressure ulcers for a resident with a stage 3 pressure ulcer on the left heel. The resident's medical record indicated that they were at risk of pressure ulcers and had a physician's order for a derma saver boot or to float the heel on a pillow at all times, as well as a foam border pressure dressing to be changed twice a week and as needed. The care plan also specified the use of these pressure-reducing devices and dressings to maintain skin integrity. Observations during the survey revealed that the resident was frequently found without the required heel boot or dressing. On multiple occasions, certified nurse aides confirmed that the dressing and boot had not been in place all morning. An administrative nurse later stated that staff were expected to follow the physician's orders and care plan, but this was not consistently done, leading to the deficiency.
Failure to Ensure Proper Transfer Procedures
Penalty
Summary
The facility failed to ensure residents received adequate supervision and assistance to prevent accidents during transfers. For Resident #30, who has cognitive deficits, self-care performance deficits related to left-sided paralysis, and is at risk for falls, the CNAs used a medium-sized harness instead of the care-planned large harness during a transfer. This resulted in the resident hanging in the lift in a sitting position with the right arm raised to chin level. The CNAs admitted they only had medium sizes available in the room, despite the care plan specifying a large harness. For Resident #40, who has cognitive deficits, weakness, and repeated falls, the CNA failed to lock the brakes on the wheelchair before assisting the resident to stand using a front-wheeled walker. This caused the wheelchair to roll backward as the resident attempted to stand. An administrative nurse confirmed that staff are expected to lock the brakes on a wheelchair prior to transferring a resident.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to provide safe and secure storage of medications for one of eight medication/treatment carts observed during medication pass. Specifically, a nurse left Unit 2's medication/treatment cart unlocked, unattended, and not within view while delivering medications to residents down the hallway. This was observed on the morning of 04/30/24. The facility's policy, revised on 03/29/24, mandates that medications be stored in a locked medication cart. An administrative nurse confirmed during an interview that the expectation is for the medication cart to be locked when not being accessed to dispense medications.
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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