Good Samaritan Society - Bottineau
Inspection history, citations, penalties and survey trends for this long-term care facility in Bottineau, North Dakota.
- Location
- 725 E 10th St, Bottineau, North Dakota 58318
- CMS Provider Number
- 355093
- Inspections on file
- 28
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Good Samaritan Society - Bottineau during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia experienced multiple incidents of mental and physical abuse from other cognitively impaired residents, including being punched, slapped, and tipped backward in a wheelchair, resulting in a head injury. Facility staff failed to supervise and intervene effectively to prevent these altercations, despite facility policy prohibiting abuse by anyone.
The facility did not thoroughly investigate multiple allegations of physical abuse between residents or ensure resident protection during the investigation process. Incidents included one resident being struck by another and another found tipped backward in a wheelchair after a verbal altercation. Required investigative steps and protections were not consistently documented or implemented.
A resident with severe cognitive impairment and total dependence for ADLs experienced a choking episode and subsequent health decline. Staff did not notify the provider or representative after the choking event or other significant changes in condition, including vomiting, hypotension, tachycardia, and low oxygen saturation. There was no documentation of provider orders for changes in care or for transport to the ER, resulting in delayed medical intervention and contributing to the resident's decline and hospitalization.
The facility did not notify the physician and/or resident representative of significant changes in condition for two residents: one who experienced a choking episode and subsequent acute changes, and another who sustained a skin tear. Documentation did not show timely notification as required by facility policy.
A resident with severe cognitive impairment and a history of wandering and aggression entered another resident's room and was found holding scissors to the resident's throat. A CNA intervened, and the resident became aggressive, requiring staff assistance. The threatened resident appeared confused and somewhat shaken, but did not report feeling scared. Facility policy required protection from abuse by anyone, including other residents.
The facility inaccurately coded the MDS for three residents, affecting the reflection of their current status and needs. One resident was incorrectly noted to have a feeding tube, another's pressure ulcer was not documented, and a third's routine use of an antipsychotic medication was omitted. These errors were confirmed by an administrative staff member.
The facility failed to follow professional standards of practice for two residents with indwelling catheters. One resident had a Foley catheter placed without specific instructions for care and maintenance in the physician orders. Another resident had an indwelling catheter without any physician orders or care instructions transcribed. These deficiencies highlight a lack of adherence to required documentation and care protocols for catheter management.
The facility experienced a 16% medication error rate due to improper administration of Fiasp insulin and polyethylene glycol. A nurse failed to prime the insulin pen correctly and did not maintain the needle in the skin for the required time. Additionally, a medication aide used insufficient water to dissolve polyethylene glycol, leaving residue in the cup. These errors were confirmed by administrative staff.
The facility failed to follow infection control standards during catheter care for two residents. A CNA did not use PPE correctly and failed to perform hand hygiene, while another CNA did not tie a gown properly, leading to potential contamination. These actions violated infection control policies and professional standards.
A resident at high risk for falls experienced multiple falls and injuries due to inadequate supervision and failure to update the care plan with effective interventions. Despite the facility's policy requiring updates and monitoring, the care plan remained unchanged, leading to continued falls and a fracture.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to provide an environment free from mental and physical abuse for a resident with severe cognitive impairment, Alzheimer's disease, dementia, and anxiety disorder. This resident experienced multiple incidents of abuse from other residents, all of whom also had severe cognitive or behavioral impairments. On several occasions, altercations occurred in common areas, including one incident where a resident was punched multiple times, another where slapping occurred between two residents, and a third where a resident was tipped backward in a wheelchair and sustained a large hematoma to the head requiring emergency room care. These events were captured on facility video footage and confirmed by administrative staff interviews. The facility's own policy stated that residents must not be subject to abuse by anyone, including other residents. Despite this, staff failed to adequately supervise the residents and did not implement interventions to prevent repeated mental and physical abuse. The lack of effective supervision and intervention allowed for ongoing resident-to-resident altercations, resulting in fear, anxiety, and physical injury to the affected resident.
Failure to Investigate and Protect Residents During Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of physical abuse involving three residents. Specifically, the facility did not ensure that all allegations of abuse were fully investigated or that residents were protected during the investigation process. The facility's own policy required that an investigation team review all events by the next working day, assign someone to complete the investigation, update care plans with new interventions, and interview relevant parties. However, documentation showed that these steps were not consistently followed for the incidents involving the sampled residents. In one incident, a resident sitting in a wheelchair was physically struck multiple times by another resident, and staff intervention occurred only after the altercation escalated. In another event, two residents were found swearing at each other, with one resident discovered tipped backward in his wheelchair holding his head. The facility lacked evidence of comprehensive investigations into these events and did not demonstrate that all residents were protected during the investigation period.
Failure to Notify Provider and Representative After Multiple Medical Incidents
Penalty
Summary
Facility staff failed to provide necessary care and services for a resident with severely impaired cognition and total dependence for ADLs, who experienced multiple medical incidents and a decline in health status. After a choking episode, staff did not notify the provider or the resident's representative, nor did they document the event in subsequent communications regarding the resident's new onset behaviors. The resident was placed on a trial pureed diet, but there was no evidence of timely provider notification or order changes following the choking event. Further, when the resident exhibited additional changes in condition—including vomiting, hypotension, tachycardia, and decreased oxygen saturation—there was again a lack of timely provider notification and no documented provider order for transport to the emergency room. The medical record also failed to show consistent provider notification regarding odorous urine and other changes in condition. These omissions delayed physician and representative input for testing, monitoring, and treatment, contributing to the resident's decline, hospitalization, and may have contributed to the subsequent death.
Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to notify the physician and/or resident representative of significant changes in condition for two residents. For one resident who experienced a choking episode, the medical record did not show that the physician or the resident's representative were informed of the incident, a subsequent change in urine, or acute changes in the resident's status, including vomiting, abnormal lung sounds, hypotension, tachycardia, and low oxygen saturation. Although the family was eventually notified and the resident was transported to the emergency room, there was no documentation of timely notification to the physician or representative regarding these significant events. For another resident who sustained a skin tear to the upper left leg, the medical record did not indicate that the resident's representative was informed of the injury. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in physical status or the need to alter treatment. An administrative nurse confirmed that staff are expected to notify the appropriate parties in such situations, but this was not documented in the records reviewed.
Failure to Prevent Resident-to-Resident Abuse Involving Sharp Object
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and aggressive outbursts entered another resident's room and was found sitting at the head of the bed holding a pair of scissors aimed at the resident's throat. The incident was discovered when a roommate alerted a CNA, who intervened and attempted to remove the scissors. The resident with the scissors became aggressive and tried to hit the CNA, requiring additional staff assistance to remove him from the room. The source of the scissors was unknown, and the resident was known to wander into other rooms to look out windows. At the time of the incident, the resident who was threatened was asleep and later appeared confused about the situation, with a CNA noting she seemed a little shaken. Interviews with the involved residents and staff indicated that neither the threatened resident nor her roommate reported feeling scared, although the CNA observed some distress. The resident who entered the room had a documented history of dementia, rejection of care, and wandering, and was independent with ambulation. Facility policy required protection of residents from abuse by anyone, including other residents.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which is crucial for reflecting their current status and needs. For one resident, the quarterly MDS inaccurately identified the presence of a feeding tube, despite the absence of any physician's orders indicating such a device during the assessment period. Another resident's MDS did not document an unhealed pressure ulcer, even though a nurse's note indicated the presence of a blister on the resident's heel shortly after returning from the hospital. Additionally, the MDS for a third resident failed to reflect the routine use of an antipsychotic medication, Seroquel, as prescribed by a physician. This discrepancy was confirmed during an interview with an administrative staff member, who acknowledged the incorrect coding of the MDS assessments for these residents. These inaccuracies in the MDS could potentially impact the development of comprehensive care plans and the care provided to the residents.
Failure to Obtain and Document Physician Orders for Catheter Care
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the management of indwelling catheters for two residents. For Resident #5, the physician orders dated June 26, 2024, included the placement of a Foley catheter, but lacked specific instructions for catheter changes, care, and maintenance. Observations during the survey confirmed the presence of the indwelling urinary catheter, and an administrative staff member acknowledged the absence of detailed care instructions in the physician orders. Similarly, for Resident #11, observations on September 16 and 17, 2024, showed the resident with an indwelling urinary catheter, yet the physician orders did not include an order for the catheter or instructions for its care and maintenance. An administrative staff member confirmed that the facility staff failed to transcribe the necessary physician orders for the indwelling catheter. These deficiencies indicate a failure to obtain and document appropriate physician orders for catheter care, which is essential for maintaining professional standards of quality care.
Medication Administration Errors Result in 16% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by a 16 percent error rate observed during medication administration for three out of five residents. Specifically, errors were noted in the administration of Fiasp insulin and polyethylene glycol. For Resident #25, a nurse primed the insulin pen incorrectly by leaving the needle cap on and pointing the pen down, contrary to the manufacturer's instructions. Additionally, another nurse administered insulin without priming the pen and failed to keep the needle in the skin for the recommended duration, leading to improper dosing. Further errors were observed with the administration of polyethylene glycol to Residents #9 and #17. A medication aide used insufficient water to dissolve the powdered laxative, resulting in undissolved residue remaining in the cup after administration. This was contrary to the manufacturer's instructions, which specified using four to eight ounces of liquid. These errors were confirmed by three administrative staff members during an interview, acknowledging the failure to adhere to the manufacturer's recommendations for medication administration.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards during catheter care for two residents, leading to potential infection risks. For Resident #5, a CNA did not don a gown or gloves before assisting with a transfer, failed to perform hand hygiene prior to donning PPE, and used a contaminated urine container in a shared bathroom sink. The resident had an indwelling urinary catheter, and the care plan indicated the need for enhanced barrier precautions (EBP), which were not followed. For Resident #11, a CNA wore a gown and gloves but did not tie the gown at the waist, causing it to fall into the workspace. The CNA changed gloves without performing hand hygiene and placed a measuring container on the floor without a barrier. The CNA also failed to rinse or cleanse the container after use. Another CNA involved in the care did not don the gown and gloves in the correct order and failed to perform hand hygiene after removing PPE. These actions violated the facility's infection control policies and procedures, as well as professional standards for PPE use.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents for a resident identified as high risk for falls. The resident, who had cognitive loss, balance deficits, and a visual deficit, experienced multiple falls over a period from March 22 to April 10, 2024. Despite being identified as high risk, the care plan only included two interventions: educating the resident and family about safety reminders and providing a fall mat to the bedside. These interventions were insufficient, as evidenced by the resident's continued falls and subsequent injuries. The facility's policy on fall prevention and management was not effectively implemented. The policy required the completion of a Falls Tool for screening and identifying fall risk factors, updating the care plan with new interventions, and monitoring the effectiveness of these interventions. However, the facility staff failed to update the care plan with new interventions after each fall, despite the resident experiencing five falls within a short period. The documentation showed that the care plan was not updated with additional interventions, and the staff did not implement any of the suggested interventions from the facility's document titled 'Suggested Resident Interventions to Manage Falls.' The resident's falls resulted in significant injuries, including a right elbow fracture. The facility's failure to implement and monitor effective fall prevention interventions and to modify the care plan as necessary contributed to the resident's continued falls and injuries. Interviews with administrative nurses confirmed that the care plan was not updated with new interventions, highlighting a lack of adherence to the facility's fall prevention policy.
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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