Western Horizons Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hettinger, North Dakota.
- Location
- 1104 Hwy 12, Hettinger, North Dakota 58639
- CMS Provider Number
- 355042
- Inspections on file
- 22
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Western Horizons Care Center during CMS and state inspections, most recent first.
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 dementia and impaired cognition eloped from the facility due to non-functioning door alarms, resulting in injuries and mild hypothermia. The resident exited through an emergency door without triggering the alarm, as it was not engaged. The facility's investigation revealed that two of six emergency exit door alarms were not engaged, and there was a lack of documentation for weekly alarm function tests.
A resident with a history of sexually inappropriate behavior engaged in unwanted sexual contact with another resident who had severe cognitive impairment. The incident was witnessed by a staff member who intervened but was unsure if it was reported. The facility's policy on abuse was not followed, and the incident was not documented in the affected resident's medical record.
A resident with a history of inappropriate behavior was observed touching another resident inappropriately. The incident was documented but not reported to the SSA as required by facility policy. An administrative nurse was unaware of the incident, confirming it was not reported, placing all residents at risk.
The facility failed to maintain sanitary conditions in food preparation and storage areas, with issues in sanitizer solution concentration and food labeling. Observations showed multiple undated and unlabeled food items in the kitchen and kitchenettes, contrary to facility policy. Dietary staff confirmed the expectation for proper labeling and discarding of outdated food items.
The facility failed to provide the required air gap for two multi-compartment sinks in the main kitchen, as per the 2018 North Dakota Plumbing Code. The drainpipes of a two-compartment sink and a three-compartment sink were joined and ended below the floor drain rim, risking contamination. Dietary staff used these sinks for food prep and thawing, while maintenance staff noted a plumber's recent work on the drainpipe.
The facility failed to maintain an effective pest control barrier, resulting in the presence of flies, gnats, ants, and a centipede in the kitchen and dining room. Observations included flies on clean glasses and gnats in the food prep area. Interviews with a resident and staff confirmed ongoing pest issues, including a mouse found in a sticky trap. The back door was improperly fitted, and an open window without a screen was noted.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. The resident was found with unlabeled medications in an open bedside drawer, and their medical record lacked an assessment or physician's order for self-administration. An administrative nurse confirmed the oversight.
A facility failed to ensure a resident and/or their representative completed the SNFABN for the termination of Medicare Part A services. The SNFABN did not indicate whether the resident or their representative chose to continue services, discontinue services, or request a demand bill. Additionally, the resident's medical record lacked documentation of their decision regarding the continuation of services with personal payment responsibility or discontinuation upon the end of Medicare Part A coverage.
The facility inaccurately coded the MDS for two residents, indicating incorrect medication administration during the look-back period. An administrative nurse confirmed the errors, which could impact care planning and delivery.
The facility failed to accurately complete a PASARR screening for a resident, omitting diagnoses of PTSD and bipolar disorder. The resident's medical record included these diagnoses, but they were not reflected in the Level 1 PASARR screening completed prior to admission. An administrative staff member acknowledged that provider diagnoses should be correctly reviewed and entered.
The facility failed to update care plans for three residents, impacting communication and continuity of care. A resident with breast cancer experienced significant weight loss without corresponding care plan updates. Another resident, observed without dentures, was identified as malnourished, yet lacked nutritional interventions in their care plan. A third resident's care plan did not address diabetes, diuretic use, anemia, and weight loss. Staff confirmed the care plans were not reviewed or revised timely.
A facility failed to maintain safe flooring, as a torn and raised strip of laminate was observed in front of a resident's recliner. The resident, with a history of falls, reported the flooring had been in disrepair for some time and often self-transfers despite needing assistance. An administrative staff member confirmed the need for repair.
The facility failed to identify trauma history and triggers for two residents with PTSD. One resident's record included a PTSD diagnosis and medication for related symptoms but lacked a trauma assessment and care plan. Another resident's care plan did not identify triggers or interventions despite a PTSD diagnosis. An administrative staff member confirmed the expectation for staff to assess potential triggers, which was not fulfilled.
A resident with ill-fitting dentures did not receive necessary assistance from the facility to obtain dental care, as required by policy. The resident was observed without dentures, had documented chewing difficulties, and experienced significant weight loss. Despite expressing a desire for new dentures, there was no documentation of appointment refusals, and the last dental exam was over a year ago. Interviews with staff confirmed the resident's prolonged lack of dentures.
The facility failed to communicate and document the allergens and food preferences of two residents, as required by its policies. One resident's preference to avoid certain vegetables was not recorded, and another resident's mushroom allergy was not noted on their diet card, despite being known by dietary staff.
A resident was placed at risk when a CNA used a hair dryer while the resident was in a tub full of water, violating the facility's safety policy. The incident was reported by the resident's family, leading to an investigation that confirmed the CNA's failure to follow safety practices.
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.
Resident Elopement Due to Non-Functioning Door Alarms
Penalty
Summary
The facility failed to ensure the safety of a resident who eloped from the building, resulting in injuries. The resident, diagnosed with dementia and adjustment disorder, was identified as having severely impaired cognition and was at high risk for elopement and falls. Despite wearing a wander guard, the resident managed to exit the facility through an emergency door without triggering the alarm, as the alarm was not engaged. The resident was found outside in cold weather, inadequately dressed, and sustained multiple abrasions and mild hypothermia. The incident occurred when the resident exited his room and left the building through an emergency exit door. The door alarm failed to sound, allowing the resident to leave unnoticed. The facility's camera footage confirmed the resident's movements and the failure of the alarm system. The resident was later found by a community member and transported to the emergency room for evaluation and treatment of his injuries. Further investigation revealed that two of the six emergency exit door alarms were not engaged, and the facility lacked documentation of weekly alarm function tests. Additionally, a staff member admitted to noticing issues with the alarms but failed to replace the batteries in a timely manner. This oversight contributed to the resident's ability to elope from the facility undetected.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from unwanted sexual contact by another resident, leading to a deficiency in ensuring residents remain free from abuse. The incident involved a resident with a history of sexually inappropriate behavior towards female staff and residents. Despite being identified as having moderate cognitive impairment and being independent for ambulation, this resident was noted to have placed his hand on the upper leg and crotch of another resident, who had severe cognitive impairment. This inappropriate contact was witnessed by a staff member who intervened by removing the resident's hand and separating the two residents. The facility's policy on abuse, neglect, and exploitation, which emphasizes the right of residents to be free from abuse, was not adhered to in this instance. The administrative nurse was unaware of the incident, and the staff member who witnessed the event was unsure if it was reported. The medical record of the resident who experienced the unwanted contact lacked documentation of the incident, indicating a failure in communication and documentation processes within the facility.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the State Survey Agency (SSA) as required by their policy. The incident involved a resident with dementia, adjustment disorder, mood disturbance, and anxiety, who was identified as having moderate cognitive impairment and a history of being sexually inappropriate. This resident was observed placing his hand on the upper leg and crotch of another resident, who had severe cognitive impairment and diagnoses of depression and anxiety. The incident was documented in a progress note but was not reported to the facility administrator or the SSA. The facility's policy on abuse, neglect, and exploitation mandates that all alleged violations involving abuse must be reported to the administrator and the SSA within 24 hours. However, the administrative nurse interviewed was unaware of the incident, confirming that it had not been reported as required. This oversight placed all residents at risk for possible abuse, as the facility did not follow its own procedures for reporting and addressing such incidents.
Sanitation and Food Labeling Deficiencies in Kitchen Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation and storage areas, as observed in one kitchen and two kitchenettes. During an interview, a dietary staff member revealed that the sanitizer solution used for cleaning food preparation areas was not functioning properly, as the automatic dispenser had parts replaced recently, and the sanitizer bucket contained only hot water. This failure to ensure the proper concentration of the sanitizer solution could compromise food safety. Additionally, the facility did not adhere to its policy on food receiving and storage, which requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Observations revealed multiple instances of food items, such as cranberry juice, sandwiches, pies, noodles, cod, churros, bread dough, garlic bread, donuts, chicken cordon bleu, chicken strips, fish sticks, corn dogs, and pork patties, that were either undated, unlabeled, or stored in unsealed bags. Dietary staff members confirmed the expectation for staff to label and date food items when opened and to discard outdated food items, which was not being followed.
Deficiency in Kitchen Sink Air Gap Compliance
Penalty
Summary
The facility failed to provide the required air gap for two multi-compartment sinks in the main kitchen, as observed during the survey. According to the 2018 North Dakota Plumbing Code, an air gap is necessary to prevent contamination in the event of a sewer back-up. The survey revealed that the drainpipes of a two-compartment sink and a three-compartment sink were joined and ended approximately two inches below the rim of a cut-out in the tiled flooring containing the floor drain, which did not meet the code's requirement for an air gap. Interviews with dietary staff members revealed that the three-compartment sink was used for thawing items in water and draining vegetables, while the two-compartment sink was used for food preparation. A maintenance staff member reported that a plumber had recently worked on the drainpipe and indicated that the current setup was necessary. However, this configuration did not comply with the plumbing code, leading to the deficiency noted in the report.
Pest Control Deficiency in Kitchen and Dining Room
Penalty
Summary
The facility failed to maintain an effective pest control barrier in the kitchen and one of the dining rooms, leading to the presence of pests such as flies, gnats, ants, and a centipede. Observations revealed flies walking across clean glasses and gnats flying in the food prep area. Dead flies and gnats were found on the window ledge and floor, and a large winged bug was observed near the ice machine. Ants and a centipede were seen crawling on the dining room floor, and flies were noted on a menu plan above the food during the evening meal. Additionally, gnats were observed near plants at the facility entrance, and an open window without a screen was found in the dining room entrance, with visible gaps between the door and frame. Interviews with residents and staff highlighted the ongoing pest issues. A resident reported an ant and fly problem in the dining room, while a dietary staff member confirmed the presence of bugs, flies, gnats, and mice, noting a mouse was found in a sticky trap the previous week. The back door was reported to not fit the foundation properly, allowing dirt to come through. A maintenance staff member mentioned that delivery personnel often leave the kitchen entrance door open and planned to replace the weather strip on the door to the outside, acknowledging the presence of a mouse earlier in the year.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, as observed during a survey. The policy in place required an interdisciplinary team to determine the safety of self-administration for each resident, and this should be documented in the care plan. However, the resident was found with unlabeled medications, including two types of eye drops and a vapor rub, in an open bedside drawer. The resident's medical record did not contain an assessment or a physician's order for self-administration of these medications. An administrative nurse confirmed the lack of assessment and physician's order, acknowledging the facility's failure to evaluate the resident's capability to self-administer medications safely.
Failure to Complete SNFABN for Medicare Part A Termination
Penalty
Summary
The facility failed to ensure that a resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for the termination of Medicare Part A services. This deficiency was identified for one of the three residents reviewed, specifically for a resident who was discharged from Medicare Part A on March 20, 2024. The SNFABN did not indicate whether the resident or their representative chose to continue services, discontinue services, or request a demand bill. Additionally, a review of the resident's medical record on July 24, 2024, revealed a lack of documentation indicating the resident's or representative's decision regarding the continuation of services with the understanding of personal payment responsibility or the discontinuation of services upon the end of Medicare Part A coverage. This oversight limited the resident's or representative's ability to exercise their rights concerning Medicare Part A services.
Inaccurate MDS Coding for Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which is essential for reflecting each resident's current status and needs. For one resident, the annual MDS indicated that the resident received an antidepressant and antibiotic during the seven-day look-back period, but the medical record did not support this. Similarly, for another resident, the quarterly MDS indicated the administration of an antianxiety medication, which was not documented in the medical record. Additionally, the Medicare five-day MDS for the same resident incorrectly indicated the administration of a hypnotic, which was also not supported by the medical record. During an interview, an administrative nurse confirmed that the staff had incorrectly coded Section N of the MDS for both residents. This inaccuracy in the MDS coding could potentially affect the development of a comprehensive care plan and the care provided to the residents, as the assessments did not accurately reflect the residents' medication usage during the specified period.
Inaccurate PASARR Screening for a Resident
Penalty
Summary
The facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASARR) for a resident reviewed with PASARR services. The deficiency was identified during a record review and staff interview. The resident's medical record included diagnoses of dementia, anxiety, dissociative identity disorder, major depression, PTSD, and bipolar disorder. However, the Level 1 PASARR screening completed by the facility prior to admission did not include the resident's diagnoses of PTSD and bipolar disorder. During an interview, an administrative staff member stated that provider diagnoses should be reviewed and entered correctly on the PASARR screening.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans for three residents, which limited staff's ability to communicate needs and ensure continuity of care. Resident #3, diagnosed with malignant neoplasm of the right breast, experienced significant weight loss, yet their care plan lacked problems, goals, and interventions related to this issue. An administrative staff member confirmed the oversight during an interview. Resident #9, who was observed without dentures, had a care plan that did not include nutritional interventions despite being identified as malnourished. The resident expressed dissatisfaction with ill-fitting dentures, and a CNA confirmed the resident had been without dentures for a long time. Resident #36's care plan was also found lacking, as it did not address issues related to diabetes, diuretic use, anemia, and excessive weight loss. The resident's medical record included diagnoses of chronic kidney disease, hypertension, edema, diabetes, altered mental status, and anemia. An administrative staff member confirmed that the care plans had not been reviewed or revised in a timely manner, contributing to the deficiency in care planning for these residents.
Deficiency in Maintaining Safe Flooring
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by a torn and raised strip of laminate flooring in front of a resident's recliner. This condition was observed during a survey, and the resident confirmed that the flooring had been in disrepair for some time. The resident, who has a history of falls, mentioned that he should ask for assistance but often self-transfers from the recliner to the wheelchair. An administrative staff member acknowledged the need for flooring replacement.
Failure to Identify Trauma Triggers for Residents with PTSD
Penalty
Summary
The facility failed to identify a history of trauma and trauma triggers for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident #4's medical record included a diagnosis of PTSD and a physician's order for Venlafaxine HCI ER to manage depression and anxiety related to PTSD. A psychiatry provider note indicated symptoms such as poor concentration, irritability, and depression following a traumatic brain injury. However, the medical record lacked a trauma assessment, identification of potential triggers, and a trauma care plan. Similarly, Resident #31's medical record identified a diagnosis of PTSD in the Minimum Data Set, but the care plan did not include triggers or interventions to prevent re-traumatization. A psychiatry provider note confirmed a past medical history of PTSD, yet the record did not contain a trauma assessment or potential triggers. An administrative staff member confirmed that they expected staff to interview the resident or family and review psychiatric notes for potential triggers related to PTSD, which was not done.
Failure to Assist Resident with Dental Care
Penalty
Summary
The facility failed to assist a resident with obtaining necessary dental care for ill-fitting dentures, which was a requirement according to their policy. The policy stated that social services personnel were responsible for helping residents make dental appointments and arrange transportation as needed. Despite this, the resident was observed without dentures throughout the survey period, and the medical record indicated issues with chewing and a significant weight loss over 180 days. The resident expressed a desire for new dentures, and a CNA confirmed that the resident had been without dentures for a long time. The facility's records lacked documentation of the resident's refusal of appointments, as mentioned by an administrative staff member. The resident's last dental exam was noted to have occurred over a year prior, and a recent oral/dental assessment highlighted the need for dental care. Additionally, a mini nutritional assessment identified the resident as malnourished, further emphasizing the impact of the lack of dental care. The deficiency was identified through observations, record reviews, and interviews with the resident and staff.
Failure to Communicate Resident Allergens and Preferences
Penalty
Summary
The facility failed to ensure that resident allergens and food preferences were properly communicated to the dietary staff, affecting two of the thirteen sampled residents. The facility's policy on food allergies and intolerances, revised in 2009, mandates that residents with food allergies and intolerances be identified upon admission to prevent exposure to allergens. Additionally, the policy on resident food preferences, revised in 2007, requires nursing staff to document residents' likes, dislikes, and special dietary instructions in their clinical records. However, these policies were not effectively implemented for Resident #6 and Resident #31. Resident #6 had expressed a preference not to be served asparagus or broccoli during a Resident Council Meeting, but this preference was not documented in their medical record or diet card. Similarly, Resident #31 had a known allergy to mushrooms, which was acknowledged by a dietary staff member, yet this allergy was not recorded on their diet card. The failure to document and communicate these dietary needs could lead to residents experiencing food intolerances or allergic reactions.
Failure to Ensure Bathing Safety
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident during a bathing session. The incident involved a certified nurse aide (CNA) who used a hair dryer while the resident was still in a tub full of water. The resident expressed concern about the safety of using the hair dryer in such conditions, but the CNA proceeded to dry one side of the resident's hair while they were still in the tub and completed the task after the resident exited the tub. This action placed the resident at risk for serious injury due to the potential hazard of using an electronic device near water. The incident was reported by the resident's family member to the Director of Nursing (DON), prompting an investigation. The facility's policy, revised in June 2024, explicitly stated that electronic devices should not be near the bathtub or shower while a resident is bathing or near standing water. The CNA's actions were in direct violation of this policy, highlighting a failure to adhere to established safety practices during resident care.
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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