Four Seasons Health Care Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Forman, North Dakota.
- Location
- 483 4th St Sw, Forman, North Dakota 58032
- CMS Provider Number
- 355103
- Inspections on file
- 22
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Four Seasons Health Care Inc during CMS and state inspections, most recent first.
Staff failed to assess and utilize the correct sling sizes for two residents during full body mechanical lift transfers, resulting in the use of slings without proper size identification or the use of an incorrect size. Staff relied on a general sizing chart in the supply room rather than individualized assessments, and there was no documentation or education provided regarding appropriate sling selection.
A resident with severe cognitive impairment was subjected to repeated unwanted sexual contact by another resident, also with severe cognitive impairment, despite staff interventions after the initial incident. The inappropriate contact occurred multiple times in a monitored lounge area before one-to-one supervision was implemented, in violation of the facility's abuse prevention policy.
A resident with COPD, pulmonary fibrosis, and CHF experienced a decline in condition, with low oxygen saturation levels and difficulty breathing. The facility failed to document nurse progress notes for several days and did not promptly assess or notify a physician of the resident's condition changes. The resident expressed distress and was eventually transferred to the ER, where he passed away shortly after arrival.
The facility failed to develop an effective QAPI process, resulting in continued noncompliance with federal regulations. Deficiencies were identified in areas such as Bed Hold Policy, Care Plan Timing, Quality of Care, Accident Hazards, Food Sanitation, and Infection Control. Despite having a policy for performance improvement, the facility did not maintain compliance, as evidenced by deficiencies cited during surveys.
The facility failed to ensure a safe, clean, and homelike environment in multiple areas, including the supply room, laundry room, oxygen storage room, and resident rooms. Observations revealed dust on an oxygen concentrator, debris in the laundry room, and damaged walls and furniture in resident rooms. Staff interviews confirmed a lack of processes for identifying areas needing cleaning or repairs.
The facility failed to accurately code the MDS for several residents, including the presence of an indwelling catheter, insulin use, and antiplatelet medication. These inaccuracies were confirmed by an administrative nurse and could affect the development of comprehensive care plans.
The facility failed to provide sufficient nursing staff, resulting in delays in care for three residents. A resident reported waiting 20-30 minutes for toileting assistance at night, while another had to wait for two staff members to assist, leading to prolonged periods in a wet pad and soreness. A third resident experienced 1-2 hour delays in receiving pain cream for knee pain across all shifts. These issues highlight inadequate staffing, particularly during the overnight shift.
The facility failed to adhere to food storage and sanitation standards, with a metal scoop improperly stored in a flour bin, an unlabeled shaker in a cooler, and expired sanitizer test strips affecting concentration results. Additionally, dried substances were found in a resident refrigerator, indicating a lack of cleanliness.
A facility failed to provide a timely written bed hold notice to a resident or their representative during a hospital transfer. The policy requires the notice to be given before transfer or within 24 hours in emergencies. However, the notice was delayed by eight days, as confirmed by an administrative staff member.
A facility failed to complete a PASARR for a resident newly diagnosed with delusions and hallucinations. Despite communication with a physician and an increase in antipsychotic medication, the facility did not update the Level I screen as required, leading to a deficiency in compliance with regulatory procedures.
The facility failed to update care plans for three residents, impacting staff communication and care continuity. A resident's care plan was not revised after a foley catheter removal, while two residents' care plans contained outdated medication information, referencing incorrect anticoagulant treatments.
A nurse failed to administer Voltaren gel according to physician orders, applying an undetermined amount directly from the tube to a resident's arms and shoulders without measuring the correct dosage. The facility's policy requires medications to be administered as ordered and in accordance with professional standards, which was not followed in this instance.
A facility failed to use a gait belt during a resident's transfer, risking falls and injury, despite the resident's history of repeated falls and a care plan requiring assistance. Additionally, a resident with dementia ingested craft paint due to an unlocked supply cabinet, leading to an ER visit. The facility's policy required such materials to be secured.
The facility failed to ensure medications were securely stored and properly dated, with a treatment cart left unlocked and unattended, and expired medications found in the medication room. An administrative staff member expected staff to lock the treatment cart when unattended.
A facility failed to follow its infection control policy during wound care for a resident. The policy requires gowns and gloves for high-contact activities to prevent the spread of multidrug-resistant organisms. A nurse changed a resident's abdominal wound dressing wearing only gloves, without a gown, and the room lacked EBP signage. The facility also did not obtain an order for enhanced barrier precautions for the resident, who required daily dressing changes.
The facility did not post accurate and complete staffing information for three days during a survey. Observations showed that the daily staffing reports were not updated as required by facility policy. An administrative staff member noted that the charge nurse was responsible for posting the daily staffing report.
Failure to Assess and Use Correct Sling Size During Mechanical Lift Transfers
Penalty
Summary
The facility failed to utilize appropriate assistive devices necessary to prevent accidents and/or injury for two residents observed during mechanical lift transfers. Specifically, staff did not assess or use the correct sling sizes for residents requiring full body mechanical lift transfers. For one resident, the sling used during transfer did not have a size noted, and for another, staff could not locate the resident's usual sling and instead used a large-sized sling without confirming its appropriateness. Staff interviews revealed that sling size information was only available on a chart in the supply room, and there was no individualized assessment or documentation of correct sling size for each resident. Further review and interviews confirmed that the facility had not assessed residents who require full body mechanical lifts for the appropriate sling size, nor had they provided staff with adequate information or education regarding proper sling selection. The lack of assessment and failure to ensure the use of correct sling sizes during transfers placed residents at risk for falls and injuries, as observed during the survey.
Failure to Prevent Repeated Sexual Abuse Between Residents with Dementia
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from repeated unwanted sexual contact by another resident, also with severe cognitive impairment. On the day of the incident, a staff member observed one resident with his face in the breast area of another resident in the lounge. When questioned, the resident stated he was just talking to her. The affected resident was removed to a safer location near the nurse's station, and the other resident was redirected to his room and counseled. Despite these interventions, the same resident was observed again shortly after kissing the affected resident on the mouth in the lounge, and later, touching her inappropriately. The affected resident was noted to have wandering behaviors and frequently entered the lounge area, which was monitored by the facility's camera system. The inappropriate sexual contact occurred three times within a short period before the facility implemented one-to-one supervision for the resident exhibiting the sexual behaviors. Both residents had diagnoses of dementia and were identified as having severe cognitive impairment on their Minimum Data Set assessments. The facility's policy stated that all residents have the right to be free from abuse, including sexual abuse, and that residents must not be subjected to abuse by anyone, including other residents. However, the facility did not prevent the repeated incidents of nonconsensual sexual contact before taking more intensive supervisory action.
Failure to Provide Timely Care and Intervention
Penalty
Summary
The facility failed to provide necessary care and services for a resident with chronic obstructive pulmonary disease, pulmonary fibrosis, and congestive heart failure. The resident's medical record lacked documentation of nurse progress notes for three consecutive days, and there was a failure to assess, monitor, and implement interventions in response to the resident's declining condition. On one occasion, the resident's oxygen saturation was recorded at 81% while on three liters of oxygen, yet there was no documented assessment, treatment intervention, or physician notification. Later, the resident's oxygen saturation improved slightly to 89%, but again, no further action was documented. The resident expressed feeling unwell and reported difficulty breathing, stating he was dying and unable to eat. Despite these significant changes in condition, there was a delay in notifying the physician, with a gap of several hours between the resident's report of distress and the facility's contact with the physician's clinic. The resident was eventually transferred to the emergency room, where he passed away shortly after arrival. The lack of timely intervention and communication with the physician contributed to the resident's decline and subsequent death.
Facility's Ineffective QAPI Process Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to develop an effective Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services and outcomes. This failure was identified through a review of the facility's QAPI program, policies, survey findings, and staff interviews. The facility's policy, dated 10/02/24, outlined a systematic approach to performance improvement, including data analysis, corrective action, and performance tracking. However, the facility did not maintain compliance with federal requirements, as evidenced by deficiencies cited during the last standard survey and a subsequent Federal Monitoring Survey. The deficiencies included issues related to the Notice of Bed Hold Policy, Care Plan Timing and Revision, Quality of Care, Accident Hazards/Supervision/Devices, Food Procurement and Sanitation, and Infection Prevention and Control. Despite the facility's policy stating that the Quality Assessment and Assurance (QAA) Committee would continue to collect and analyze data to ensure improvements, the facility failed to effectively utilize its Quality Assurance processes. This resulted in continued noncompliance with federal regulations, as indicated by the deficiencies cited under F625, F657, F684, F689, F812, and F880.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several areas, including the supply room, laundry room, oxygen storage room, and resident rooms. Observations during the survey revealed an oxygen concentrator with dust on the outside and filter, and oxygen tubing and a mask were found on the floor beside the machine. Additionally, a portable liquid oxygen tank and a nebulizer machine were also placed on the floor next to the concentrator. In the laundry room, there was visible dust and debris on a fan grate and blades, which were blowing into the clean laundry area. The oxygen storage room had two ceiling vents with a thick layer of dust, cracked and broken floor tiles, a visible layer of fine dirt along the floor perimeter, and ceiling tiles with water leak marks. In the resident rooms, Unit A had scuff marks, chipped paint, and gouges on the walls. Room B8 had an overbed table with a two-inch strip of missing laminate along the front length, exposing the wood, and a large area of loose laminate on the right top side. The top of the oxygen concentrator in room B8 was also covered in dust. During interviews, a maintenance staff member confirmed the lack of a process for identifying areas needing cleaning or repairs and was unaware of any resident room concerns. An administrative staff member stated that staff were expected to clean and sanitize oxygen and nebulizer equipment before storage and dispose of items like oxygen tubing and masks in the resident's room.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for eight residents, which is crucial for reflecting each resident's current status and needs. Specifically, the facility did not accurately code the presence of an indwelling catheter for one resident, as the MDS indicated its presence despite observations and medical records showing otherwise. Additionally, the facility failed to code insulin use for another resident who had physician orders for insulin glargine to manage diabetes mellitus type 2. Furthermore, the facility did not code the use of antiplatelet medication, specifically aspirin, for six residents on their respective MDS assessments. These omissions were confirmed by an administrative nurse during interviews, highlighting a pattern of inaccurate MDS coding across multiple residents. This inaccuracy in MDS coding could potentially impact the development of comprehensive care plans and the care provided to the residents.
Insufficient Nursing Staff Leads to Delays in Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, as evidenced by confidential interviews with three residents. Resident A reported a consistent wait time of 20-30 minutes for toileting clean-up assistance during the night shift, which had been ongoing since their admission several weeks prior. Resident B expressed that the facility was understaffed, requiring two staff members for assistance, resulting in prolonged periods of sitting in a wet pad and developing soreness. This issue was particularly noted after evening care and throughout the night. Resident C experienced delays of 1-2 hours in receiving pain cream for knee pain, with these delays occurring across all shifts. These findings indicate a failure to provide adequate staffing to meet the residents' needs, particularly during the overnight shift.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards in both the kitchen and a resident refrigerator. During a kitchen tour, a metal scoop was found improperly stored inside a flour bin, contrary to the facility's policy that requires scoops to be kept outside storage bins in protective containers. Additionally, an unlabeled and undated shaker containing milk and oatmeal was found in a reach-in cooler, which was identified as belonging to a staff member. This lack of labeling and dating contravenes the facility's policy on food safety, which mandates that all food brought into the facility be labeled and dated. Furthermore, the facility did not ensure the proper concentration of sanitizer solution used for cleaning resident dining room tables. An unidentified dietary staff member tested the sanitizer concentration and found it to be out-of-range, with the test strips used being expired. This could potentially affect the effectiveness of the sanitizer. Additionally, dried liquid substances were observed on two shelves inside a refrigerator located in the main lobby, which is used to store foods brought in by family members. The dietary manager confirmed the expectations for food storage and acknowledged the expired test strips, which may have affected the sanitizer test results.
Failure to Provide Timely Bed Hold Notice
Penalty
Summary
The facility failed to provide a timely written bed hold notice to a resident or their representative during a hospital transfer. According to the facility's policy, a written notice detailing the bed hold policy should be provided before a resident is transferred to the hospital, or within 24 hours in the case of an emergency transfer. However, for one resident who was transferred to the hospital, the facility delayed providing this notice until eight days after the transfer. This delay was confirmed by an administrative staff member during an interview, indicating a lapse in adhering to the facility's policy and regulatory requirements.
Failure to Complete PASARR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a status change assessment for a resident who was newly diagnosed with mental illness, specifically delusions and hallucinations. According to the North Dakota PASARR Provider Manual, a change in status process must be initiated when a significant change in a resident's mental health status occurs. This includes contacting the contracted agency to update the Level I screen and determine if a Level II evaluation is necessary. The resident's medical record indicated that a PASARR was completed in August 2021, but subsequent progress notes in September 2024 documented communication with a physician regarding the resident's delusions and hallucinations, leading to an increase in antipsychotic medication. However, there was no evidence that the facility staff completed a PASARR related to these new diagnoses. During an interview, a social services staff member confirmed that the facility did not complete a change in status Level I screen for the resident. This oversight could result in the delivery of care and services that do not align with the resident's current needs, as the facility did not follow the required procedures for updating the resident's mental health status. The lack of a completed PASARR assessment following the emergence of new mental health conditions represents a deficiency in the facility's compliance with regulatory requirements.
Failure to Update Care Plans Following Medical Changes
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of three residents, which limited the staff's ability to communicate needs and ensure continuity of care. For Resident #4, the care plan was not updated to reflect the removal of a foley catheter, as confirmed by an administrative nurse during an interview. Despite the absence of an indwelling catheter observed on 10/28/24, the care plan still indicated its presence. For Resident #10, the care plan inaccurately referenced monitoring for bleeding problems due to Plavix use, despite a physician's order for Eliquis, an anticoagulant medication. Similarly, Resident #23's care plan was not updated after the discontinuation of warfarin on 05/01/24, as it still included instructions for PT/INR checks and Coumadin dose adjustments. These discrepancies highlight the facility's failure to update care plans following significant changes in residents' medical treatments.
Failure to Administer Topical Medication as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of topical medication for a resident. During a medication pass, a nurse was observed applying Voltaren gel to a resident's arms and shoulders without measuring the correct dosage as specified in the physician's orders. The orders required the application of 2 grams of Voltaren gel to the shoulders and 4 grams to the knees, but the nurse dispensed an undetermined amount directly from the tube into a gloved hand, failing to use the dosing card as per the manufacturer's specifications. The deficiency was confirmed through observation, record review, and staff interviews. The facility's medication administration policy mandates that medications be administered as ordered by the physician and in accordance with professional standards. The administrative staff acknowledged that the nurse did not follow the provider's orders for accurately measuring and applying the medication, which could potentially lead to adverse outcomes for the resident.
Failure to Utilize Gait Belt and Secure Hazardous Materials
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for a resident during a gait belt transfer. A licensed nurse assisted the resident to stand up from a sitting position by placing her arm under the resident's arm, failing to utilize a gait belt during the transfer. The resident's medical record indicated repeated falls, and the care plan required staff assistance with transfer and locomotion. This failure to use a gait belt placed the resident at risk for falls and/or injury. Additionally, the facility failed to ensure the safety of a resident who ingested non-toxic craft paint. The resident, who had diagnoses of dementia, restlessness, agitation, and wandering, was found with craft paint on his arms, mouth, and pants. The nurse was unsure of how much paint the resident might have consumed, and the resident was sent to the ER for evaluation. The facility's incident report noted that the cabinet containing the paint was unlocked, despite staff being aware that it should always be locked to prevent access by residents with altered mental status.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly dated, expired medications were discarded, and medications were securely stored in two of three storage areas, specifically the treatment cart and medication room. During an observation, a staff nurse left a treatment cart unlocked and unattended for approximately 20 minutes while entering a resident's room. During this time, residents and staff walked past the unlocked cart, and one resident stood next to it without the nurse present. This lack of security could lead to unauthorized access to medications. Additionally, an observation of the medication room revealed that a locked refrigerator contained expired medications and an undated multi-dose vial. Specifically, three acetaminophen suppositories had expired on 12/31/23, and an opened, undated multi-dose vial of tubersol was found. An administrative staff member stated that she expected staff to lock the treatment cart when it was unattended or out of sight, indicating a failure to adhere to facility policies regarding medication storage and security.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy during wound care for a resident. The policy, titled Enhanced Barrier Precautions (EBP), requires the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multidrug-resistant organisms. During the survey, it was observed that a staff nurse entered the resident's room, which lacked EBP signage, and proceeded to change the resident's abdominal wound dressing while only wearing gloves, neglecting to wear a gown as mandated by the facility's policy. Additionally, the facility staff did not obtain an order for enhanced barrier precautions for the resident, who had a wound on the right abdomen requiring daily dressing changes as per the physician's order.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to ensure the posting of accurate and complete staffing information on three out of four days during the survey period from October 27 to October 29, 2024. This deficiency was identified through observation, review of facility policy, and staff interviews. The facility's policy requires the posting of daily staffing information for each shift, detailing the number of licensed and unlicensed staff responsible for resident care. However, observations revealed that the facility did not update the staffing reports on the clipboard located by the nurse's station during the specified days. An administrative staff member indicated that the charge nurse was expected to complete and post the daily census/staffing report.
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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