Good Samaritan Society - Lakota
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakota, North Dakota.
- Location
- 608 4th Ave Sw, Lakota, North Dakota 58344
- CMS Provider Number
- 355104
- Inspections on file
- 22
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Good Samaritan Society - Lakota during CMS and state inspections, most recent first.
Two residents with pressure ulcers did not receive adequate care as per physician's orders and facility policy. One resident had multiple pressure ulcers with inconsistent weekly assessments and measurements, while the other was observed without required heel protector boots, leading to increased ulcer size. An administrative staff member confirmed the lack of adherence to interventions and documentation requirements.
A facility failed to obtain a physician order for a resident's indwelling urinary catheter, despite the resident's history of urinary retention and recurrent UTIs. The resident returned from the hospital with a catheter, but the facility did not document an order for its use or specify the frequency of changes. An administrative staff member confirmed the lack of documentation.
The facility failed to monitor a resident's respiratory condition, leading to a hospital transfer, and did not apply a positioning device for another resident, resulting in poor posture. Additionally, the facility did not follow physician orders for a third resident's arm swelling treatment.
The facility failed to provide an air gap for the main kitchen's food-preparation sink, as required by the North Dakota Plumbing Code. This deficiency was observed when a continuous drainage pipe was found without a visible air gap, potentially allowing contamination. The environmental services director confirmed the absence of the air gap, indicating non-compliance with the code.
The facility failed to maintain food safety and sanitation standards in the main kitchen and resident nutrition center. Observations showed food items lacking date marking, discolored broccoli, and improperly stored meat products. Expired test strips were used for sanitation testing, and ice packs were stored with food. The nutrition services director confirmed the lack of compliance with policies.
A facility failed to notify a resident's physician about missed blood tests for a resident with chronic kidney disease. The resident had orders for a BMP, but staff were unable to draw blood on two occasions due to difficulty finding a vein. The facility's policy required immediate notification of the physician for significant treatment changes, but there was no documentation of such notification. An administrative nurse confirmed the missed draws and stated the provider would be notified on the next rounds.
The facility did not provide the State LTC Ombudsman with a notice of transfer for a resident reviewed for hospital transfers. The resident's medical record showed multiple hospital transfers, but there was no evidence of transfer notices being sent to the ombudsman. An administrative staff member confirmed the oversight during an interview.
The facility failed to accurately code the MDS for two residents, affecting the reflection of their current status and needs. One resident with mental health conditions was incorrectly coded in Section A1500, while two residents had inaccurate weight loss documentation in Section K. These errors could impact care planning and provision.
A facility failed to adhere to prescribed wound care orders for a resident with a stage IV pressure ulcer. The resident's care plan required specific steps, including cleansing, applying collagen powder, packing with calcium alginate, and using specific foam dressings and skin protectant. However, during an observation, a nurse did not apply the calcium alginate, 2x2 nonbordered foam, or skin protectant, deviating from the physician's orders.
The facility failed to provide appropriate G-tube care for two residents. One resident's tube feeding bag was not labeled with necessary information, and another resident continued to receive tube feeding despite a dietician's recommendation to discontinue it due to weight gain. An administrative nurse confirmed these deficiencies.
The facility failed to adhere to oxygen therapy orders and tubing protocols for three residents. One resident wore oxygen continuously at 2 lpm against orders for 1 lpm as needed, with undated tubing and no record of tubing changes. Another resident wore oxygen at 2 lpm instead of the prescribed 3 lpm at rest and 5 lpm with activity, with similar issues in tubing documentation. A third resident wore oxygen at 3 lpm continuously, contrary to orders, with undated tubing and no evidence of regular changes.
A facility failed to identify tampering with a controlled medication container for a resident. A medication aide found a tablet of Gabapentin taped into a Hydrocodone/acetaminophen container, indicating tampering. This occurred despite a policy requiring nurses to check for tampering.
The facility experienced an 8% medication error rate due to improper administration for two residents. A resident received Ipratropium-Albuterol Inhalation without necessary assessments and documentation, while another resident was given Potassium Chloride ER tablets incorrectly crushed in pudding. The errors were confirmed by administrative staff, highlighting non-compliance with medication administration protocols.
The facility failed to follow infection control standards for two residents under enhanced barrier precautions. A nurse did not wear the required PPE while handling a resident's tube feeding, and a therapy staff member assisted another resident with exercises without donning a gown and gloves. These actions were confirmed by an administrative nurse.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing or prevent the development of pressure ulcers for two residents. For the first resident, the medical record review revealed a history of urinary tract infections and clostridium difficile, with multiple pressure ulcers identified. Despite physician's orders for weekly skin assessments and specific wound care, the facility staff did not complete weekly assessments and measurements for the resident's wounds. The records showed inconsistencies in documenting wound measurements, with some assessments missing measurements entirely and others not conducted weekly as required by the facility's policy. The second resident's medical record indicated two unstageable pressure ulcers, with physician's orders for heel protection and offloading to prevent further deterioration. Observations showed the resident in a recliner without the required heel protector boots, contrary to the physician's orders. The facility staff also failed to complete weekly wound measurements for this resident, with records showing gaps in documentation and an increase in the size of the pressure ulcers over time. An interview with an administrative staff member confirmed the facility's failure to ensure interventions were followed and that the medical records lacked the necessary weekly wound measurements. This deficiency in care and documentation could potentially lead to the deterioration of existing pressure ulcers and the development of new ones, as the facility did not adhere to its own policies and physician's orders for pressure ulcer management.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with an indwelling urinary catheter. The resident, who had a history of urinary retention, pressure ulcers, resistance to multiple antimicrobial drugs, and recurrent urinary tract infections (UTIs), returned to the nursing home from the hospital with a catheter. Despite the presence of the catheter, the facility did not obtain a physician's order for its use or specify how often it should be changed. Progress notes indicated that the catheter was draining yellow urine and was replaced on a specific date, but there was no documented physician order for the catheter in the resident's medical record. An administrative staff member confirmed the absence of this order during an interview.
Failure to Monitor Health Changes and Follow Care Plans
Penalty
Summary
The facility failed to provide adequate care and services to maintain the highest level of well-being for Resident #30, who experienced a change in health status that led to a hospital transfer. Despite the resident's complaints of increased shortness of breath and the need for higher oxygen levels, the facility did not monitor or assess the resident's condition on an ongoing basis. The medical record showed a lack of evidence of physician notification and respiratory assessments, resulting in a delay in treatment and subsequent hospital admission. Additionally, the facility did not ensure proper care for Resident #1, who was care planned for a positioning device to prevent leaning in her wheelchair. Observations revealed that the resident was frequently seen leaning to the left without the required positioning device in place. Staff interviews confirmed that the positioning pad was supposed to be used but was not consistently applied, indicating a failure to assess and address the resident's positioning needs. Furthermore, the facility did not follow physician orders for Resident #16, who required a geri-sleeve and sling for swelling in the left arm. Observations showed that these devices were not applied as ordered, and a nurse admitted to forgetting to apply them. This oversight resulted in the facility's failure to adhere to the physician's orders, potentially impacting the resident's condition.
Lack of Air Gap in Kitchen Sink
Penalty
Summary
The facility failed to provide an air gap for the food-preparation sink in the main kitchen, as required by the 2018 North Dakota Plumbing Code. This deficiency was identified during an observation on June 17, 2024, at 10:30 a.m., where it was noted that a continuous drainage pipe passed into the wall without a visible air gap. The absence of an air gap in the food-preparation sink has the potential to allow contamination in the event of a sewer backup and bacterial migration, which is a violation of the plumbing code. The North Dakota Plumbing Code, specifically Section 801.2 and 801.3.3, mandates that food-preparation sinks must be indirectly connected to the drainage system by means of an air gap. This requirement is to ensure that there is a minimum vertical distance of not less than 1 inch from the lowest point of the indirect waste pipe to the flood-level rim of the receptor. During an interview on the same day, the environmental services director confirmed the lack of an air gap, highlighting the facility's non-compliance with the plumbing code.
Food Safety and Sanitation Deficiencies in Kitchen and Nutrition Center
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in both the main kitchen and the resident nutrition center. Observations revealed multiple instances of food items lacking proper date marking, including individual servings of mandarin oranges, a large container of blended shredded cheese, and various other food items such as lemon lime juice, Italian dressing, and picante sauce. Additionally, discolored broccoli was found, and several packages of meat products in the walk-in freezer were not sealed or dated. A section of pipe in the freezer was covered with ice, dripping water onto a box of food below, causing water damage and ice accumulation. The ice and water dispenser panel was also found to be covered in mineralization and debris. Expired test strips were used for testing cleanser solutions and chlorine levels in the dishwasher, compromising the effectiveness of sanitation procedures. In the resident nutrition center, several food items, including cheddar cheese dip, pizza rolls, and ice cream, were found without open dates. Ice packs were improperly stored with food items, which was confirmed by an administrative staff member. The nutrition services director acknowledged the lack of date marking and stated that staff are expected to follow policy and procedures.
Failure to Notify Physician of Missed Blood Tests
Penalty
Summary
The facility failed to notify a resident's physician of a change in condition, specifically missed blood tests, for a resident with chronic kidney disease. The resident had physician orders for a basic metabolic panel (BMP) on two occasions, which were not completed due to unsuccessful blood draws. Despite several staff attempts, they were unable to find a vein in the resident's upper extremities. The facility's policy required immediate notification of the physician when there is a need to alter treatment significantly, but the medical record lacked documentation of such notification. An administrative nurse confirmed the missed blood draws and stated that the provider would be notified on the next rounds.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide the State Long Term Care Ombudsman with a notice of transfer for a resident who was reviewed for hospital transfers. This deficiency was identified through a record review and staff interview. The resident's medical record showed hospital transfers on three separate occasions, but there was no evidence that the facility provided the ombudsman with copies of the transfer notices. An administrative staff member confirmed during an interview that the facility did not send the notices to the ombudsman prior to the survey date.
Inaccurate MDS Coding for Mental Health and Weight Loss
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which is essential for reflecting their current status and needs. For one resident, diagnosed with schizoaffective disorder, bipolar type, generalized anxiety disorder, and personality disorder, the facility incorrectly coded Section A1500 of the MDS. Despite a PASRR Level II Outcome indicating a mental health condition, the MDS inaccurately recorded a 'no' response regarding the resident's serious mental illness status. This error was confirmed by a social services staff member during an interview. Additionally, the facility inaccurately documented weight loss for two residents in Section K of the MDS. For one resident, a significant change MDS indicated weight loss, but the records did not support a 5% or more weight loss in 30 days or a 10% or more weight loss in 180 days. Similarly, another resident's quarterly MDS noted weight loss without evidence of the specified percentage loss in the records. These inaccuracies in the MDS coding could potentially impact the development of comprehensive care plans and the care provided to the residents.
Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate treatment and services for the healing of pressure ulcers for one resident with a current pressure ulcer. The resident had a healing stage IV pressure ulcer on the coccyx, with specific physician's orders for wound care that included cleansing the wound, applying collagen powder, packing with calcium alginate, covering with specific foam dressings, and applying skin protectant. During an observation, a nurse did not follow these orders completely, as they only cleansed the wound with saline spray, applied collagen powder, and covered it with a 4x4 bordered dressing, omitting the calcium alginate, 2x2 nonbordered foam, and skin protectant. This deviation from the prescribed wound care regimen was identified during the survey.
Deficiencies in G-tube Care and Communication
Penalty
Summary
The facility failed to ensure appropriate gastrostomy tube (G-tube) care and services for two residents, leading to deficiencies in their care. For one resident, the facility did not label the tube feeding bag with necessary identifying information such as the type of formula, date, time, or nurse's initials. This resident was observed with an empty tube feeding bag connected, with formula still visible in the tubing, indicating a lack of proper labeling and monitoring. An administrative nurse confirmed that the expectation was for all tube feeding bags to be labeled with at least the date and time, which was not adhered to in this case. For another resident, the facility failed to communicate and implement the dietician's recommendations regarding tube feedings. Despite a dietician's note advising the discontinuation of nighttime tube feeding due to continued weight gain, the facility continued to administer the tube feeding as per the previous orders. This resident was observed to have G-tube feeding bags and a pump in their room, and staff confirmed the continuation of tube feeding at night, contrary to the dietician's updated recommendations. An administrative nurse acknowledged the failure to discontinue the feeding as recommended.
Failure to Adhere to Oxygen Therapy Orders and Tubing Protocols
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards and the residents' plans of care for three residents receiving oxygen therapy. Resident #2 was observed wearing oxygen via nasal cannula at 2 liters per minute (lpm) continuously, despite physician orders specifying 1 lpm as needed for specific conditions. Additionally, the oxygen tubing was undated, and there was no evidence in the medication administration record (MAR) of regular tubing changes. Resident #15 was observed wearing oxygen at 2 lpm, contrary to physician orders for 3 lpm at rest and 5 lpm with activity. The tubing was also undated, and the MAR lacked documentation of tubing changes. Resident #30 was observed wearing oxygen continuously at 3 lpm, although the physician's orders specified no oxygen at rest and 1 lpm with exertion. The resident reported needing more oxygen recently and wearing it at all times. The oxygen tubing was undated, and the MAR did not show evidence of tubing changes. An administrative nurse acknowledged the need to clarify the residents' oxygen orders and expected staff to change the oxygen tubing weekly.
Failure to Recognize Tampered Medication Container
Penalty
Summary
The facility failed to recognize tampering with a controlled medication container for a resident. During an observation, a medication aide discovered that one of the 16 tablets of Hydrocodone/acetaminophen, an opioid pain medication, was different from the others and taped into the container. An administrative nurse identified the tablet as Gabapentin, a non-opioid pain medication, confirming that the medication card had been tampered with. This incident occurred despite the facility's policy requiring on-coming nurses to physically examine controlled medication containers for evidence of tampering, such as open packages or medications that look different from others.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an 8% error rate during medication administration for two residents. For Resident #136, a medication aide administered Ipratropium-Albuterol Inhalation without completing the required pre and post-assessment, and failed to document vital signs and the total time spent with the resident, as per the physician's orders. This oversight was confirmed by an administrative nurse, indicating non-compliance with the facility's medication administration policy. For Resident #7, a medication aide incorrectly crushed and administered Potassium Chloride ER tablets in pudding, contrary to the proper method of dissolving the tablets in water or juice. The medical record lacked specific instructions on how to administer this medication, leading to the error. An administrative staff member confirmed the incorrect administration and the absence of detailed orders, contributing to the medication error.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for two residents under enhanced barrier precautions. Resident #27, who had a tube feeding order, was observed with a sign on the door indicating enhanced barrier precautions. However, a nurse added water to the resident's tube feeding bag, flushed the line, and disconnected the tube feeding without wearing the required gown and gloves. This was confirmed by an administrative nurse during an interview, who stated that staff are expected to wear PPE for tube feedings. Similarly, Resident #31 was also under enhanced barrier precautions, as indicated by a sign on the door. A therapy staff member entered the room and assisted the resident with therapy exercises without donning the necessary gown and gloves. This was also confirmed by an administrative nurse, who acknowledged that therapy staff should wear gowns and gloves when working with residents under enhanced barrier precautions.
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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