Dunseith Com Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunseith, North Dakota.
- Location
- 15 1st St Ne, Dunseith, North Dakota 58329
- CMS Provider Number
- 355080
- Inspections on file
- 18
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Dunseith Com Nursing Home during CMS and state inspections, most recent first.
Two residents experienced abuse, including yelling, intimidation, and threats by staff, as well as physical altercations between residents. Staff failed to use proper de-escalation techniques, did not maintain resident dignity, and did not report incidents or injuries promptly to supervisory staff, resulting in unaddressed physical and mental distress.
Staff failed to promptly report an incident where a resident with cognitive impairment and behavioral health diagnoses was subjected to yelling, distress, and improper handling by multiple CNAs during a transfer. The resident was left naked on the bathroom floor, found crying with unexplained scratches, and the full details were not communicated to the charge nurse or reported to authorities within the required timeframe.
A resident with chronic pain and dementia exhibiting agitation experienced multiple episodes of pain and aggressive behavior toward staff and other residents. Despite these documented incidents, the care plan was not updated to address pain management or behavioral interventions, and administrative staff confirmed the need for revisions. The facility also could not provide its care plan policy when requested.
The facility did not ensure that the dietary manager had completed the required certification or education to serve as the director of food and nutrition services, as the manager had not finished the certified dietary manager course and was working under an extension.
The facility did not ensure that its high temperature dishwasher consistently sanitized dishware, as staff only recorded external gauge readings and did not check plate-level temperatures. When a dish thermometer was used, it took multiple cycles to reach the required 160°F, and the facility's own thermometer was not functional, resulting in inadequate monitoring of dish sanitization.
The facility did not ensure its QAA Committee met quarterly as required, missing meetings in two quarters and failing to include the medical director in any meetings, as confirmed by administrative staff and review of meeting minutes.
Staff did not adhere to professional standards during insulin administration, including improper priming of insulin pens and failure to notify a physician about out-of-range blood glucose levels for a resident with diabetes. These actions were not in accordance with facility policy and were confirmed by administrative staff.
A resident's financial power of attorney was not provided with required quarterly financial statements for the resident's personal fund account, as confirmed by both the representative and business office staff. This omission prevented the representative from verifying account transactions and balances.
A nurse did not follow infection control protocols during a wound dressing change for a resident with chronic wounds. Supplies were placed on an unsanitized bedside table without a barrier, and the nurse failed to change gloves or perform hand hygiene between steps, contrary to facility policy. An administrative nurse confirmed the lapse in infection control practices.
The facility failed to provide appropriate dementia care for a resident with dementia, agitation, and insomnia, who exhibited wandering and inappropriate sexual behaviors. The resident frequently intruded into other residents' rooms, causing distress and safety concerns. The facility did not adequately assess or manage these behaviors, nor did they implement effective interventions, compromising the dignity, privacy, and safety of other residents.
The facility failed to ensure food was stored in accordance with professional standards for food service sanitation in the main kitchen. Observations revealed rusty and rough surfaces on food storage racks, a build-up of black debris on the fan grate, and significant ice build-up in the walk-in freezer, including on food items.
The facility failed to follow infection control standards during medication administration and wound care for multiple residents. A nurse did not remove gloves and perform hand hygiene after performing blood sugar checks and administering insulin, and another nurse was observed double gloving while treating a resident's wounds, which is not the facility's practice.
The facility failed to ensure dignity and provide privacy during personal cares for two residents, with staff entering rooms without knocking or announcing themselves. Additionally, a staff nurse left the treatment cart unattended with residents' eMARs visible on multiple occasions, risking unauthorized viewing of resident records.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident. Observations revealed a strong urine odor, sticky floors, dirty wheelchair cushions, and various debris. Interviews with CNAs and an administrative nurse confirmed the need for cleaning attention, and the facility's policy on routine cleaning and disinfection was not followed.
The facility failed to accurately code the MDS for two residents, affecting the accuracy of their assessments and potentially their care plans. One resident's therapeutic diet was not reflected in the MDS, and another resident's significant weight loss was incorrectly coded as being on a physician-prescribed weight-loss regimen.
The facility failed to review and revise care plans for three residents, limiting staff's ability to communicate needs and ensure continuity of care. One resident was at risk for elopement, another had advanced dementia with behavioral issues, and a third was a fall risk with a recent fracture. Despite these conditions, their care plans lacked necessary interventions.
The facility failed to notify the physician of critical changes in a resident's systolic blood pressure and weight, despite specific orders to do so. This failure was confirmed by an administrative nurse and placed the resident at risk for delayed treatment and adverse health events.
The facility failed to provide timely toileting assistance to a resident, as required by their care plan. Observations and records showed that the resident was not assisted every two to three hours, resulting in wet clothing and a strong odor of urine. Staff confirmed the resident should be toileted regularly, but there were 20 instances of non-compliance, with gaps of 7 to 16 hours between assistance.
The facility failed to deposit residents' funds in an interest-bearing account for two residents. A review of a quarterly statement and an interview with business office employees confirmed that the funds were kept in a non-interest-bearing checking account.
Failure to Protect Residents from Abuse and Inadequate Response to Incidents
Penalty
Summary
The facility failed to protect two residents from abuse, including verbal, mental, and physical abuse by staff, as well as resident-to-resident altercations. One resident with anxiety, conduct disorder, depression, and moderate cognitive impairment was subjected to yelling, intimidation, and threats by multiple CNAs during an attempt to assist her with toileting. Staff were observed hollering at the resident, pointing in her face, and insisting she apologize while she was naked and distressed on the bathroom floor. The resident was found crying with fresh scratches on her arm, which staff could not adequately explain. Staff also threatened to withhold snacks as a form of punishment, and failed to report the incident and injuries to the charge nurse in a timely manner. Another resident with dementia and agitation exhibited behaviors that led to two separate resident-to-resident altercations. In one incident, the resident was found holding another resident's arm and struck the other resident in the face with a closed fist. In a separate event, the same resident hit another resident in the mouth during a verbal outburst in the activity room. Both incidents resulted in staff intervention to separate the residents and assess for injuries, though no significant injuries were noted at the time. The facility's policies on abuse, neglect, and exploitation were not followed, as evidenced by staff's failure to prevent and appropriately respond to abusive behaviors, both from staff to resident and resident to resident. Staff did not use appropriate de-escalation techniques, failed to maintain residents' dignity, and did not ensure timely and accurate reporting of abuse or injuries to supervisory staff.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
Facility staff failed to report an incident of abuse involving a resident with anxiety, conduct disorder, moderate cognitive impairment, and delusions within the required timeframe. The incident involved multiple certified nurse aides (CNAs) attempting to get the resident up for supper, during which the resident was distressed, yelling, refusing to cooperate, and ultimately ended up naked on the bathroom floor. A gait belt was applied directly to the resident's bare skin, and staff lifted her with it at least once. Several CNAs were reported to have yelled at the resident, pointed in her face, and insisted she apologize. Another CNA later found the resident crying on the floor with scratches on her left arm, which no staff could explain. The resident was then calmed, cleaned, dressed, and brought to supper. The charge nurse was only informed that the resident had a behavior and that a gait belt was used, but was not told about the yelling, the resident being on the floor naked, the number of staff involved, or any injuries. The full details of the incident were not reported to the charge nurse at the time. The facility reported the incident to the State Survey Agency (SSA) six days after the event, which was not within the required two-hour timeframe. An administrative nurse confirmed that the incident was not reported in a timely manner and acknowledged that it was unacceptable for staff to holler at or threaten residents.
Failure to Update Care Plan for Resident with Pain and Aggression
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain and dementia with agitation, despite multiple documented incidents indicating changes in the resident's condition. The resident's medical record showed 21 instances of pain or requests for pain medication, two occasions of verbal or physical aggression with other residents, and 23 occasions of verbal or physical aggression with staff over a period of approximately two months. The current care plan did not include problems, goals, or interventions addressing the resident's pain or aggressive behaviors. During staff interviews, administrative staff confirmed that the care plan required updates and revisions to reflect the resident's current status. Additionally, the facility was unable to provide a copy of their care plan policy when requested.
Unqualified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the dietary manager had obtained the required qualifications to serve as the director of food and nutrition services. During an interview, the dietary manager stated that she had not completed the certified dietary manager course and had only received an extension to complete it. As a result, the facility did not have a dietary manager who had completed the necessary education for certification as a dietary manager, certified food service manager, or held a national certification for food service management and safety from a recognized certifying body.
Failure to Ensure Adequate Heat Sanitization of Dishware
Penalty
Summary
The facility failed to ensure that the high temperature dishwasher in the main kitchen provided adequate heat sanitization for dishes and utensils. Observations showed that the dishwasher was in use, but the dietary staff only documented temperature readings from the external temperature gauge/dial and did not check dishwash temperatures at the plate level during wash/rinse cycles. When a surveyor's dish thermometer was used, it required up to five wash/rinse cycles before the thermometer registered the required 160 degrees Fahrenheit or above, indicating inconsistent or inadequate sanitization. Additionally, the dietary manager confirmed that staff did not routinely monitor dish temperatures at the plate level and that the facility's dish plate thermometer was not functioning due to a dead battery. The lack of a process or functioning thermometer to verify adequate heat sanitization of dishware contributed to the deficiency, as the facility could not ensure that dishware was being properly sanitized according to professional standards and regulatory requirements.
Failure to Hold Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) Committee met at least quarterly and included all required members, as specified in its own policy. Review of QAA Committee meeting minutes revealed that the committee did not meet during two of the five reviewed quarters, specifically in June and September of 2024. Additionally, the medical director did not attend any of the QAA Committee meetings during the review period. An administrative staff member confirmed that the committee had not met on a quarterly basis and that the medical director's required attendance was not ensured.
Failure to Follow Professional Standards in Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to follow professional standards of practice during insulin administration for four residents observed. Specifically, nurses were seen priming insulin pens incorrectly, either with the needle cap on or while holding the pen downward, contrary to facility policy which requires the needle cap to be off and the pen to be held upright during priming. These observations were confirmed by an administrative nurse who stated the expected procedure was not followed. Additionally, for one resident with Type 2 diabetes mellitus, staff did not notify the physician when blood glucose readings were outside the parameters set by the physician's order. The resident's medical record showed multiple instances of blood sugar levels below 100 mg/dL and above 450 mg/dL, but there was no documentation that the physician was informed as required by facility policy. This was acknowledged by an administrative nurse during interview.
Failure to Provide Quarterly Financial Statements to Resident's Representative
Penalty
Summary
The facility failed to provide the resident's designated financial representative with quarterly financial statements for the resident's personal fund account, as required by facility policy. Review of the policy confirmed that individual financial records must be made available to the resident through quarterly statements. Interviews revealed that the resident's financial power of attorney had not received any such statements, and a business office staff member confirmed that the statements were not sent. This failure prevented the representative from verifying the resident's financial transactions and fund balances.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow the facility's infection prevention and control policy during a wound dressing change for a resident with chronic wounds on the posterior left thigh and bilateral buttocks. The facility's policy required sanitizing the overbed table, placing a barrier before setting up supplies, and performing hand hygiene and glove changes between steps of the dressing change. However, the nurse placed supplies directly on the bedside table without sanitizing it or using a barrier, and did not change gloves or perform hand hygiene between removing the soiled dressing, cleansing the wound, and applying the new dressing. The resident's medical record included physician orders for specific wound care and a care plan addressing impaired skin integrity. During the observed dressing change, the nurse removed soiled dressings, cleansed the wounds, and applied new dressings without following the required infection control steps. An administrative nurse confirmed that proper infection control practices were not followed during this procedure.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for a resident diagnosed with dementia, agitation, and insomnia, who exhibited wandering behaviors and a history of inappropriate sexual behaviors. The resident's medical record indicated multiple incidents of wandering into other residents' rooms, aggressive behaviors, and sexually inappropriate actions towards both residents and staff. Despite these behaviors, the facility did not adequately assess and monitor patterns or trends, nor did they develop an effective behavior management program or person-centered care plan to address these issues. Observations and interviews revealed that the resident frequently wandered into other residents' rooms, sometimes attempting to disrobe or engage in inappropriate behaviors. Staff and other residents reported feeling unsafe and disturbed by these actions. One resident specifically mentioned feeling unsafe and requested a lock on their door due to the frequent intrusions and inappropriate behavior of the resident in question. Staff interviews confirmed the difficulty in redirecting the resident and the negative impact on other residents. The facility's response to the resident's behaviors was insufficient, as they only placed a picture of the resident on his door to help him locate his room more easily. The social service member was unaware of the extent of the resident's sexual behaviors towards others. The facility's failure to implement effective interventions and modify the physical environment compromised the dignity, privacy, and safety of other residents, and did not support the resident in achieving the highest level of functioning.
Failure to Ensure Proper Food Storage Sanitation
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards for food service sanitation in the main kitchen. Observations revealed several deficiencies, including rusty and rough surfaces on food storage racks in the walk-in cooler, which a dietary staff member confirmed were difficult to clean. Additionally, there was a build-up of black debris on the grate of the fan on the ceiling. In the walk-in freezer, there was a significant amount of ice build-up on a pipe, the back north wall, the back east wall, and the ceiling. This ice build-up was also found in an open box of sherbet cups, on packages of coffee, and above a bag of garlic toast and other boxes of food. The facility's policy on sanitation inspections, dated 03/01/24, mandates daily inspections of refrigerators and freezers by food service staff and weekly inspections of all food service areas by the dietary manager. However, the observations made on 04/29/24 and 05/02/24 indicated that these inspections were either not conducted as required or were ineffective in identifying and addressing the sanitation issues. The failure to maintain clean and sanitary conditions in the food storage areas has the potential to result in foodborne illness or adverse effects for patients, visitors, and staff.
Infection Control Deficiencies During Medication Administration and Wound Care
Penalty
Summary
The facility failed to follow standards of infection control for five of fifteen sampled residents during medication administration and resident care. Specifically, a nurse did not remove gloves and perform hand hygiene after performing blood sugar checks and administering insulin to multiple residents. The nurse was observed exiting residents' rooms, disinfecting equipment, placing supplies back into the medication cart, and typing on the computer without changing gloves or performing hand hygiene. This was observed with residents who had chronic conditions and infections, including MRSA and VRE, and were on enhanced barrier precautions. Additionally, another nurse was observed double gloving while treating a resident's wounds, which is not the facility's practice. The nurse did not remove gloves and perform hand hygiene before and after cleansing the wounds and applying medications. This failure to adhere to proper infection control practices has the potential to transmit infections to residents, staff, and visitors. An administrative nurse confirmed that double gloving is not the facility's practice.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure dignity and provide privacy during personal cares for two residents. In one instance, a CNA entered a resident's room without knocking or announcing themselves, which the resident confirmed happens frequently. In another instance, two CNAs were providing care to a resident when a third CNA entered the room without knocking or announcing themselves. These actions violated the facility's policy on promoting and maintaining resident dignity and privacy, which requires staff to knock and announce themselves before entering a resident's room. Additionally, the facility failed to promote privacy and confidentiality of electronic medication administration records (eMAR). A staff nurse left the treatment cart unattended with residents' eMARs visible on four separate occasions. This failure to lock computer screens and ensure the privacy of resident information could result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff. These actions are contrary to professional guidelines that emphasize the importance of maintaining the privacy and confidentiality of client information stored in computers.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for one resident. Observations in the resident's room and bathroom revealed a strong urine odor, a sticky floor with a rust-colored substance around the toilet, and multiple unclean areas including dried food/drink spills on the wall, dirty wheelchair cushions, dust on a shelf, and various debris on the floor. The housekeeping logs and the resident's medical record did not show any evidence that the resident refused housekeeping services. Interviews with two CNAs revealed that the resident did not like the wheelchair cushions from physical therapy and had thrown them on the floor. The CNAs acknowledged that the cushions should have been returned to physical therapy and that the room needed cleaning attention. An administrative nurse also agreed that the room required cleaning. The facility's policy on routine cleaning and disinfection was not followed, leading to the unsanitary conditions observed in the resident's room.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which impacted the accuracy of their assessments and potentially the development of their comprehensive care plans. For Resident #21, the medical record showed a physician's order for a low potassium diet dated 04/27/23. However, the annual MDS did not reflect this therapeutic diet in section K0510D. This discrepancy was acknowledged by the dietary manager during the survey interview on 05/02/24. For Resident #27, the medical record indicated a significant weight loss of 10% over three months, from an admission weight of 125 lbs on 01/25/24 to 111.8 lbs on 04/24/24. Despite this, there were no physician orders for a weight loss regimen. The admission MDS incorrectly coded section K0300 as 'yes,' indicating the resident was on a physician-prescribed weight-loss regimen. This error was confirmed by a nurse manager during an interview on 05/01/24.
Failure to Review and Revise Care Plans
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 #13 was identified as at risk for elopement, with a physician's order for a Wanderguard check three times a day. Despite this, the resident's care plan lacked any mention of wandering or the use of a Wanderguard. Similarly, Resident #23, who had advanced dementia and a history of behavioral issues including wandering and sexually inappropriate behaviors, had no care plan addressing these issues. Observations confirmed the resident's wandering behavior, but the care plan did not reflect any interventions for these behaviors. Resident #179 had a fall resulting in a right elbow fracture prior to admission and was identified as a fall risk with a provider order for maximum fall precautions. Observations showed the resident with a cast, sling, and a chair alarm attached to the wheelchair, yet the care plan lacked any interventions related to fall precautions. An administrative nurse confirmed that the care plan should indicate specific fall precautions for the resident. These deficiencies highlight the facility's failure to update and revise care plans to reflect the current needs and risks of the residents, potentially impacting the quality of care provided.
Failure to Notify Physician of Critical Changes in Resident's Condition
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with specific parameters for weight and blood pressure monitoring. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, chronic bronchitis, hypertension, renal failure, and anemia. Despite physician orders to notify the medical doctor if the resident's systolic blood pressure fell below 100 mmHg or if there was a weight change of 4 pounds or more, the facility did not notify the physician of 12 occurrences of systolic blood pressure below 100 mmHg and four occurrences below 90 mmHg. Additionally, significant weight changes were recorded without notifying the physician, including an 8-pound loss and a 6.4-pound gain within a short period. An administrative nurse confirmed that the staff failed to notify the provider of these changes during an interview. The failure to notify the physician of these critical changes in the resident's condition placed the resident at risk for delayed treatment and adverse health events. The deficiency was identified through a combination of record reviews, professional reference reviews, and staff interviews.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident who required staff assistance with toileting. The care plan for the resident indicated that staff should assist with toileting every two to three hours. However, observations and record reviews revealed that the resident was not assisted as required, resulting in the resident being found with wet clothing and a strong odor of urine on multiple occasions. Specifically, there were 20 instances where staff did not assist the resident with toileting within the specified time frame, with gaps ranging from 7 to 16 hours between assistance. During an interview, two certified nurse aides confirmed that the resident should be toileted every two to three hours. The facility's policy and professional references emphasize the importance of regular toileting to prevent skin breakdown, infection, and other complications. Despite this, the facility failed to adhere to the care plan and policy, leading to the resident experiencing incontinence episodes without timely assistance from staff.
Failure to Deposit Resident Funds in Interest-Bearing Account
Penalty
Summary
The facility failed to deposit residents' funds in an interest-bearing account for two residents. A review of a quarterly statement from the pooled account revealed it was a non-interest-bearing account. During an interview, two business office employees confirmed that they keep petty cash available for residents on weekends and maintain money for each resident in a pooled checking account at the bank. The individual account sheets for the two residents showed that their money was in a non-interest checking account.
Latest citations in North Dakota
Surveyors found that the facility did not follow its policy requiring monthly cleaning and disinfection of personal fans by environmental services, as evidenced by dust and debris on small oscillating fans in the rooms of two residents, who reported that fans were not cleaned regularly and were only addressed when staff had time. Observations also revealed environmental disrepair in several rooms, including missing paint, sharp and rough wood on a cabinet under a sink, and moisture damage with warped molding in a bathroom. An environmental staff member acknowledged that these rooms needed repair, and the report notes that failure to maintain clean equipment and a safe, clean, and sanitary environment may result in injuries, diminish the homelike living area, and does not promote overall quality of life.
The facility failed to ensure proper cleaning and sanitization of dishware and utensils in the Special Care Unit kitchenette by not monitoring or documenting the mechanical dish-washing machine’s wash and rinse temperatures as required by facility policy and FDA Food Code standards. Staff reported they did not check the machine’s temperature gauges or maintain a temperature log, despite the dishwasher being used multiple times daily. During surveyor testing with an irreversible temperature device, the first cycle did not reach the facility’s minimum required temperatures, and only on a second cycle did the wash, rinse, and utensil surface temperatures meet or exceed the specified thresholds, confirming that required temperature monitoring was not being performed.
Two residents were observed partially or fully undressed in their rooms without adequate privacy, despite care plans and a resident rights policy requiring a dignified existence. One fully dependent resident was seen in bed with pants pulled down and a brief exposed while the room door was ajar. Another resident with generalized pruritus, who remains unclothed from the waist down due to itching and had a privacy curtain in place for this purpose, was repeatedly observed asleep in a recliner naked from the waist down with the room door open and the curtain not used, leaving the resident exposed to visitors, staff, and other residents.
The facility failed to prevent resident-to-resident abuse in two separate incidents involving vulnerable residents with dementia and behavioral histories. In one case, a male resident with known inappropriate sexual behaviors was found by a CNA in a female resident’s room, sitting on her bed, kissing her, and touching her breasts under her shirt, despite her later stating she did not like the contact and a provider determining she could not consent due to cognition. In another case, a male resident with psychosis, intermittent explosive disorder, traumatic brain injury, and a history of aggression toward others struck a cognitively impaired female resident on the cheek because her noise bothered him, later stating she deserved it. These events occurred despite care plans and policies that identified the residents’ behavioral risks and prohibited abuse by other residents.
The facility failed to follow its abuse policy by not reporting an alleged resident-to-resident physical altercation to the State Survey Agency. A resident with severe cognitive impairment and dementia-related diagnoses was reportedly struck hard on the cheek by another cognitively impaired resident with psychosis, intermittent explosive disorder, TBI, and a history of hitting other residents when overstimulated by noise. A staff member documented the report of the incident and assessed the resident, finding no injury, and the resident stated she was okay. Despite the facility policy requiring prompt reporting of all alleged abuse and submission of investigation results, an administrative staff member confirmed that this incident was never reported to the State Survey Agency.
A resident experienced a decline in condition, and a nurse documented a phone call to the physician resulting in a hospice referral, followed by a documented hospice nurse visit to assess the resident’s status. Despite hospice services being initiated, the resident’s medical record did not contain the required hospice election form. During a staff interview, facility personnel confirmed that the hospice election form was missing from the record, and the report notes that this failure may have limited staff’s ability to ensure coordination of care between the facility and the hospice.
The facility failed to follow infection control standards for a resident receiving nebulizer treatments. Resident Council minutes documented that two residents had previously raised concerns about nebulizer tubing being left on the floor. Surveyors later observed on multiple occasions that a nebulizer mask and tubing were lying on the floor next to a resident’s recliner, and the resident reported that the nebulizer machine, mask, and tubing were always kept on the floor, rather than on a clean surface.
The facility failed to follow its own skin breakdown policy requiring notification of the attending provider, resident, and resident representative when new pressure injuries or lower extremity wounds develop or worsen. A resident with severe cognitive impairment developed MASD to the buttocks and a heel wound that progressed from suspected deep tissue injury to an unstageable pressure ulcer with black eschar, leading to an urgent podiatry referral. The medical record contained no documentation that the resident’s representative was informed of these wounds, their progression, or new treatment orders, and the family later reported they had not been told, despite an LPN confirming that families are supposed to be notified of new wounds, changes, and related treatments.
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.
A resident with mild vascular dementia, agitation, and a documented history of socially inappropriate and physically aggressive behaviors punched another cognitively impaired resident with traumatic brain injury and dementia in a common area. Staff heard yelling and then observed the aggressor standing over the injured resident with a raised fist after the punch. The aggressor admitted he intended to cause pain and expressed no remorse. The injured resident reported facial and headache pain, with redness noted on the left side of the face, and was evaluated in the ED before returning with mild residual redness and reduced pain.
Failure to Maintain Clean Equipment and Safe, Homelike Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents, specifically related to cleanliness of personal fans and needed room repairs. Review of the facility’s February 2025 “Personal Fans” policy showed that personal fans were required to be cleaned and disinfected at least monthly by environmental services staff. However, observations over several days in February 2026 found dust and debris on small oscillating fans in the rooms of Resident #10 and Resident #13. Resident #10 reported that rooms were cleaned weekly but the fans were not cleaned often, and Resident #13 stated that staff cleaned fans only when they had time. An environmental staff member confirmed that personal fans should be cleaned monthly. Additional environmental deficiencies were observed in resident rooms. In Resident #42’s room, surveyors noted an area of missing paint approximately 5 inches by 3 inches. In Resident #47’s room, there was missing paint and sharp or rough pieces of wood on the cabinet under the sink, as well as walls with missing paint. In Resident #82’s bathroom, there was moisture damage to the wall and warped molding. An environmental staff member confirmed that the rooms of Residents #42, #47, and #82 required repair. The report states that failure to maintain clean equipment and a safe, clean, and sanitary environment may result in injuries, diminish the homelike living area for residents, and does not promote overall quality of life.
Failure to Monitor and Achieve Required Dishwashing Temperatures in SCU Kitchenette
Penalty
Summary
The facility failed to ensure dishware and eating utensils were properly cleaned and sanitized in the Special Care Unit (SCU) kitchenette, which utilized a mechanical dish-washing machine. Facility policy for the SCU dish sanitizer, dated January 2025, required that dishes be handwashed in hot soapy water, rinsed, placed in a single layer in the dish sanitizer, and sanitized using an electric booster designed to raise the water to 180°F, with minimum water temperatures of 150°F for the wash cycle and 180°F for the rinse cycle. The 2022 FDA Food Code specified that mechanical warewashing equipment must follow manufacturer instructions for wash solution temperature and that hot water sanitization must achieve a utensil surface temperature of at least 160°F, as measured by an irreversible registering temperature device. During observation of the SCU kitchenette with a supervisory dietary staff member, surveyors noted that the mechanical dish-washing machine was used three times daily and that dietary staff identified it as using heat to sanitize dishware and utensils. When surveyors requested a temperature log for the wash and rinse cycles, an unidentified staff member stated that staff did not check the temperature gauges on the dish machine and had never kept a log. An irreversible temperature measuring device placed in the dish machine during a cycle showed that the wash and rinse temperatures did not reach the minimum temperatures required by facility policy. On a second cycle, the wash gauge reached 155°F, the rinse gauge reached 195°F, and the irreversible temperature device reached 165°F. The supervisory dietary staff member confirmed that staff should monitor the dish machine to ensure proper temperatures are reached to wash and sanitize dishware and utensils.
Failure to Maintain Resident Dignity and Privacy in Resident Rooms
Penalty
Summary
Surveyors found that the facility failed to provide care in a manner that maintained, enhanced, and respected resident dignity and privacy for two sampled residents. For one resident who was totally dependent on staff for toileting hygiene, product changes, and clothing adjustment, observations on two occasions showed the resident lying in bed uncovered, with pants pulled down under the buttocks and the brief exposed, while the room door was ajar. For another resident with generalized pruritus who, according to the care plan, sits with no clothes on in the room because fabric causes itching and who does not like the door closed tightly, a privacy curtain had been placed in the room to provide privacy when the resident was naked. However, observations on two occasions showed this resident asleep in a recliner, naked from the waist down, with the room door open and staff not using the privacy curtain, leaving the resident exposed to visitors, staff, and other residents. The facility’s own Resident Rights policy, dated 11/17/16, stated that the resident has the right to a dignified existence, but staff actions and inactions in these observed situations did not ensure privacy or dignity for the two residents while they were partially or fully undressed in their rooms.
Failure to Prevent Resident-to-Resident Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident physical and sexual abuse, for two sampled residents. Facility policy on Abuse, Neglect and Exploitation, revised 02/13/24, states that residents must not be subject to abuse by anyone, including other residents, and defines sexual abuse as non-consensual sexual contact of any type with a resident and physical abuse as including hitting. Despite this policy, the facility did not prevent incidents in which one resident engaged in sexual contact with another resident who was unable to consent, and another resident struck a peer. In the first incident, a CNA witnessed a male resident in a female resident’s room, sitting on her bed, kissing her, and touching her breasts under her shirt. Nursing staff immediately intervened and separated the residents. The female resident had diagnoses including Alzheimer’s disease, dementia with behaviors, mild intellectual disabilities, and obsessional thoughts and acts; her care plan noted she seeks out male attention and sometimes makes unsafe decisions. Progress notes documented that she did not show signs of distress during the incident but later reported that a male resident had entered her room, touched her inappropriately, and stated, “I did not like it.” A provider determined she was unable to consent to sexual activity or a relationship due to her cognition. The male resident involved had dementia with behaviors, and his care plan identified a behavior problem related to making inappropriate touching, kissing, and comments toward females, with a prior episode of touching a female resident. In the second incident, a male resident with psychosis, delusions, intermittent explosive disorder, traumatic brain injury, and mild intellectual disabilities, whose care plan noted he “explodes” when there is a lot of noise and that he has hit other residents and pushed them with his wheeled walker, struck another resident on the cheek. A dietary aide reported that he hit a female resident on the cheek because her noise near the nurse station bothered him in his room. The male resident told staff he did it because she was always making noise and said she “deserved it.” The female resident he struck had diagnoses including Alzheimer’s disease, dementia with psychotic disturbance, hallucinations, and anxiety, with severely impaired cognition. She was assessed with no injury noted and stated she was okay but believed the other resident did not like her. An administrative staff member confirmed the facility investigated both incidents, but the facility failed to protect these residents from physical and sexual abuse.
Failure to Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, and exploitation policy by not reporting an alleged resident-to-resident physical altercation to the State Survey Agency (SSA). The facility’s policy, dated 02/13/24, required that all alleged violations involving abuse be reported immediately, but no later than 2 hours if the events involved abuse or resulted in serious bodily injury, or within 24 hours if they did not involve abuse and did not result in serious bodily injury, and that investigation results be reported within 5 working days. For one sampled resident and one supplemental resident reviewed for resident-to-resident altercations, the facility did not make the required report to the SSA. Record review showed that one resident had diagnoses including Alzheimer’s disease, dementia with psychotic disturbance, hallucinations, and anxiety, with a quarterly MDS indicating severely impaired cognition. A progress note documented that a dietary aide reported this resident was struck hard on the cheek by another resident while going to the dining room; the aide stated the other resident stopped, said something, and then struck the resident when she made a noise. The writer assessed the resident and found no injury, and the resident stated she was okay but felt the other resident did not like her. The other resident involved had diagnoses of psychosis, delusions, intermittent explosive disorder, traumatic brain injury, and mild intellectual disabilities, with a quarterly MDS indicating moderately impaired cognition and a care plan noting a history of hitting other residents and pushing them with a wheeled walker when overstimulated by noise. During an interview, an administrative staff member confirmed the facility failed to report this incident to the SSA.
Missing Hospice Election Form in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the medical record for a resident receiving hospice services contained a hospice election form. Record review for Resident #85 showed that on 01/02/26 a nurse documented a phone call to the physician’s office regarding a decline in the resident’s condition, during which a hospice referral was given. A subsequent nurse’s note dated 01/07/26 documented that a hospice nurse visit was completed to assess the resident’s status, confirming that hospice services had begun. However, despite the initiation of hospice care, the resident’s medical record did not contain the required hospice election form. During an interview on 02/26/26, a facility staff member confirmed that the hospice election form was missing from Resident #85’s record, and the report states that this failure may have limited staff’s ability to ensure coordination of care between the facility and the hospice. This lack of documentation occurred for 1 of 1 closed records reviewed for residents who received hospice services, indicating that the facility did not obtain or maintain the hospice election form in the resident’s chart even after hospice referral and visits were documented.
Improper Storage of Nebulizer Equipment on Floor
Penalty
Summary
The deficiency involves the facility’s failure to follow infection prevention and control standards of practice for a resident receiving nebulizer treatments. Resident Council meeting minutes dated 10/17/25 documented that two residents had raised concerns about nebulizer tubing being left on the floor. Subsequent surveyor observations on 02/23/26 at 2:07 p.m. and 3:25 p.m., on 02/24/26 at 8:37 a.m., and on 02/26/26 at 12:56 p.m. showed a nebulizer mask and tubing lying on the floor next to Resident #82’s recliner. During an interview on 02/26/26 at 12:56 p.m., Resident #82 stated that the nebulizer machine, mask, and tubing are always kept on the floor. The report notes that failure to ensure nebulizer masks and tubing are on a clean surface may result in contamination of the items and lead to respiratory infections. These findings demonstrate that, despite prior resident concerns documented in Resident Council minutes, the facility did not ensure that nebulizer equipment for Resident #82 was stored on a clean surface, resulting in repeated observations of the mask and tubing on the floor.
Failure to Notify Resident Representative of New and Worsening Wounds
Penalty
Summary
The facility failed to notify a resident’s representative of new and changing wounds and related treatment orders, as required by its own policy and regulatory expectations. The facility’s 2018 policy on Prevention and Treatment of Skin Breakdown required licensed nurses to perform weekly skin audits and, when a new pressure injury or lower extremity wound developed, to notify the attending provider, the resident, and the resident representative, and to educate them on the wound and care plan interventions. The policy also required notification of the attending provider, resident, and resident representative if a pressure injury failed to show progress in two weeks or deteriorated unexpectedly, with documentation reflecting these notifications. Record review for one resident with severe cognitive impairment (BIMS score of 3) identified wounds to the buttocks and right back heel, including moisture-associated skin damage (MASD) to the right medial buttock first noted as redness on 09/29/25 and later documented as new MASD with excoriation on 11/05/25. The right back heel was documented as a new suspected deep tissue injury on 11/11/25, which progressed to an unstageable pressure ulcer with mostly black eschar by 11/18/25, followed by an urgent podiatry referral order on 11/20/25. The medical record lacked documentation that the resident’s representative was notified of the buttock and heel wounds, their progression, or the new treatment orders. In interview, a family member stated they were not aware of the buttock wound or the heel ulcer, and a staff nurse confirmed that facility policy is to notify resident families of new wounds, changes in existing wounds, and related orders/treatments.
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 Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse when one resident with a known history of socially inappropriate and physically aggressive behaviors punched another resident in the face. The facility’s Abuse Prevention Plan policy required identification, correction, and intervention in situations where abuse occurs, assessment of residents whose behaviors might lead to conflict, and development of an individual abuse prevention plan that includes the resident’s risk of abusing others and specific measures to minimize that risk. Despite this policy, a resident with documented behaviors such as threatening harm to other residents, being verbally aggressive, and a history of becoming physically abusive toward other residents was able to physically assault another resident. The assaulted resident had diagnoses of traumatic brain injury and dementia with behaviors, with a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition. On the day of the incident, staff heard hollering from the commons area and then observed the aggressive resident standing over the other resident with a raised fist after having already punched him in the face. The aggressive resident admitted to punching the other resident because he was upset about a comment made to his female companion and stated that he intended to cause pain and did not care about the consequences. Following the punch, the injured resident complained of pain in the left temporomandibular area, with redness noted and an increasing headache rated 7–8/10 and facial pain rated 2/10. The resident was sent to the emergency department for further evaluation. Later documentation indicated the resident returned with mild redness on the left side of the face, no bruising developing, and reported facial pain of 1/10 with denial of headache. The surveyor determined that this incident constituted verified abuse under the facility’s definitions and that the facility failed to ensure residents remained free from abuse as required by policy and regulation.
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