Good Samaritan Society - Larimore
Inspection history, citations, penalties and survey trends for this long-term care facility in Larimore, North Dakota.
- Location
- 501 E Front St, Larimore, North Dakota 58251
- CMS Provider Number
- 355097
- Inspections on file
- 22
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Good Samaritan Society - Larimore during CMS and state inspections, most recent first.
Two residents with pressure ulcers did not receive consistent repositioning or timely application of protective devices as ordered, and staff failed to document these interventions. One resident's care plan was not updated to include a repositioning schedule for nearly a month after deep tissue injuries were identified, and there were significant delays in coordinating wound care referrals, resulting in deterioration of wounds and hospitalization.
Staff did not use a gait belt while assisting a resident with a transfer from a wheelchair to a recliner, despite the resident's documented need for assistance due to weakness. During the transfer, the resident's knees gave out, resulting in a fall in which the resident struck her head and sustained a right hip fracture. The facility's policy required gait belt use during transfers, but this was not followed, leading to the incident.
The facility did not ensure that the person acting as dietary manager had completed the required education or held a national certification for food service management and safety. The dietary manager was still enrolled in a certification course and had not yet finished it.
The facility did not establish or utilize an effective QAPI process to identify and address deficiencies in care planning, incontinence management, nursing staffing, medication errors, and food service sanitation. Audits were conducted, but there was a lack of monitoring in the specific areas cited, leading to ongoing noncompliance.
The facility did not employ a staff member with specialized training in infection prevention and control to oversee the Infection Prevention and Control program, as confirmed by policy review and staff interviews.
Care plans for four residents were not updated to reflect current physician orders and resident needs, including missing documentation for blood sugar monitoring, oxygen requirements, pain management, edema interventions, and accurate fluid restrictions. These deficiencies limited staff communication and continuity of care.
Multiple residents and family members reported long wait times for call light responses, delays in toileting assistance, and inadequate hygiene support due to insufficient CNA staffing. Staffing records confirmed that the facility did not consistently provide the necessary number of CNAs or a bath aide on several days, resulting in unmet resident needs and delays in care.
The facility did not consistently provide or distribute snacks to residents according to their needs and preferences. Residents reported that snacks were often left at the nurse's station and not delivered to rooms, with one diabetic resident noting the impact on their care. Observations showed snacks being left unattended and touched by residents, and staff confirmed that snack delivery was not their responsibility.
Surveyors found improper food storage practices, including food boxes placed directly on an iced freezer floor, personal items such as medication and cola stored in the kitchen refrigerator, and large bundles of flowers kept in the walk-in refrigerator. These actions violated facility policy and professional standards, as confirmed by administrative staff.
A resident with severe cognitive impairment repeatedly engaged in inappropriate sexual behaviors towards female residents, including touching and making advances, despite existing care plan interventions. Staff intervened during incidents and documented them, but the facility did not recognize these actions as sexual abuse or update interventions to prevent recurrence. The affected residents included individuals with dementia and memory issues.
A resident with severe cognitive impairment was involved in multiple incidents of inappropriate sexual contact with another resident. Although staff intervened and documented the events, the facility did not report these incidents of resident-to-resident sexual abuse to the State Survey Agency as required by policy.
Surveyors found that the facility did not accurately code the MDS for three residents, including failing to document a diagnosis related to an indwelling catheter for a resident with BPH and not coding antiplatelet medication use for two residents taking daily aspirin. These omissions were confirmed by staff interviews.
A newly admitted resident with diabetes and hydrocephalus did not have an accurate baseline care plan developed, as the plan misidentified medication purposes, failed to address insulin use and blood sugar interventions, and omitted necessary interventions for hydrocephalus. Administrative staff confirmed the care plan did not reflect the resident's actual clinical needs.
A resident who was permitted to smoke independently was repeatedly found smoking in unauthorized indoor and entryway areas, despite staff instructions and facility policy requiring use of a designated outdoor area. Surveyors also observed that cigarettes and lighters were stored in an unlocked box with the key left in place, and staff interviews revealed inconsistent understanding and enforcement of smoking material security procedures.
Two residents requiring staff assistance with toileting and incontinence care did not receive scheduled checks, changes, or appropriate interventions as outlined in their care plans. Staff failed to consistently check briefs, encourage toileting, provide education, or notify nursing staff of refusals, resulting in prolonged periods without care and inadequate documentation of refusals.
A resident receiving hemodialysis for chronic kidney disease did not have documentation of communication from the dialysis unit regarding their condition during and after treatments. Staff confirmed that while necessary documents were sent with the resident, no handoff information was received from the dialysis facility, resulting in a failure to monitor and document the resident's post-dialysis status as required by facility policy.
Surveyors observed that staff failed to follow proper medication administration procedures, including crushing medications that should not be crushed and incorrectly priming insulin pens, resulting in a medication error rate of fifteen percent. Errors included a medication aide crushing delayed-release and extended-release tablets before administration to a resident, and a nurse priming insulin pens incorrectly for two residents.
The facility did not post accurate daily nurse staffing information, as the forms displayed in a common area did not correctly reflect the number of unlicensed staff on duty for each shift. Both administrative and scheduling staff confirmed the inaccuracies during the survey.
Failure to Prevent Worsening of Pressure Ulcers and Delayed Wound Care Referrals
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent the worsening of pressure ulcers for two residents with existing pressure ulcers. For one resident admitted with pressure ulcers to the left ankle and sacrum, the care plan included interventions such as encouraging and assisting with turning, and physician orders required repositioning every two hours and the use of protective boots while in bed. However, the medical record did not show evidence that staff consistently repositioned the resident or applied the protective boots as ordered. An administrative staff member confirmed the lack of documentation for these interventions. For another resident admitted with a diagnosis of spinal cord compression, the initial physician's orders did not identify or address pressure ulcers. Four days after admission, deep tissue injuries to both buttocks were identified, and wound care orders were obtained the following day. The care plan was not updated to include a repositioning schedule until approximately one month after the injuries were first noted, despite wound assessments recommending repositioning every 2-3 hours. The medical record lacked evidence that staff implemented the recommended repositioning schedule. Additionally, the facility failed to process and coordinate timely referrals for wound care. There were delays in following up on wound clinic referrals, and the provider did not evaluate the resident's wound during a bedside visit. The resident's wounds deteriorated, progressing to a stage 4 pressure injury with acute cellulitis, and required hospitalization. The facility also did not provide a policy for processing referrals to outside agencies, contributing to the delay in wound care follow-up.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents during a staff-assisted transfer for one resident. Specifically, staff did not use a gait belt while transferring a resident from a wheelchair to a recliner, despite the resident's care plan indicating a need for assistance due to self-care performance deficits related to weakness. During the transfer, the resident's knees gave out, resulting in an assisted fall in which the resident struck her head on a dresser and subsequently sustained a right hip fracture. The incident was documented in the facility's reported incident and medical records, which noted the resident experienced significant pain and was sent to the emergency room for evaluation. The facility's policy on gait belt use, which was in effect at the time, required gait belts to be used during transfers to aid patients and protect them from accidental trauma. The failure to follow this policy and utilize the gait belt during the transfer directly led to the resident's fall and injury.
Unqualified Dietary Manager Directing Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the individual serving as the dietary manager had obtained the required qualifications to direct the food and nutrition services. During an interview, the dietary manager stated that he was currently enrolled in a certified dietary manager course but had not yet completed it. As a result, the facility did not have a dietary manager who had completed the necessary education or held a national certification for food service management and safety, as required.
Failure to Implement Effective QAPI Process
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems, improve services and outcomes, and ensure compliance with federal requirements. Review of state agency files showed the facility did not maintain compliance in several areas, including care plan timing and revision, bowel/bladder incontinence, sufficient nursing staff, medication errors, and food procurement and sanitation, as evidenced by deficiencies cited during the last standard survey. During staff interviews, an administrative staff member indicated that while departments conducted various audits monthly, there was a lack of awareness regarding monitoring of the specific areas cited, except for care planning. This lack of an effective QAPI process resulted in continued noncompliance in the identified areas.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to employ an individual who had completed specialized training in infection prevention and control to be responsible for the Infection Prevention and Control program. Review of the facility's policy confirmed that the Infection Preventionist must have completed such specialized training. During staff interviews, an administrative nurse confirmed that no staff member with the required specialized training was employed to oversee the infection prevention and control program. This deficiency was identified through review of employee files, facility policy, and staff interviews.
Failure to Update and Revise Care Plans to Reflect Residents' Current Needs
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of four residents. For one resident, the care plan did not include required blood sugar monitoring and did not update oxygen needs as per the physician's order. Another resident's care plan listed Enhanced Barrier Precautions (EBP) without documenting a related diagnosis or problem, and failed to address pain management despite an active order for oxycodone. A third resident's care plan did not identify the problem or interventions related to edema, even though the resident was prescribed furosemide for this condition. Additionally, a fourth resident's care plan incorrectly documented the fluid restriction, listing 200 cc instead of the physician-ordered 2000 cc with specific allocations for dietary and nursing shifts. These omissions and inaccuracies were confirmed by administrative staff during interviews, and the facility's policy requires care plans to be updated as residents' needs or statuses change. The lack of timely and accurate care plan updates limited staff's ability to communicate resident needs and ensure continuity of care.
Insufficient Nursing Staff Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and related services to meet the needs of all residents, as evidenced by multiple documented concerns from resident council meeting minutes, resident and family interviews, and staffing record reviews. Residents reported excessive wait times for assistance with toileting, lack of clean towels over weekends, delayed trash removal, and call lights being turned off without addressing their needs. Specific accounts included residents waiting up to an hour for call light responses, experiencing incontinence due to delays, and staff shortages, particularly with only one CNA on the floor at times. Staff interviews confirmed that CNA staffing was only increased after a recent census rise, and staffing records showed that the facility did not consistently maintain the increased CNA coverage, missing adequate staffing on four days and lacking a bath aide on two days within a 13-day period. These findings were corroborated by both resident and family observations of insufficient staff and prolonged wait times for care.
Failure to Consistently Provide and Distribute Snacks to Residents
Penalty
Summary
The facility failed to provide snacks to residents in accordance with their needs and preferences, as evidenced by observations, resident council meeting minutes, and interviews. Resident council minutes over several months documented ongoing concerns about the inconsistency of evening snack distribution, with residents reporting that snacks were not reliably passed and that they often had to request them. One resident, who is diabetic, specifically noted that snacks were left at the nurse's station and not delivered to residents' rooms, which occurred frequently and impacted their ability to manage their condition. On the day of observation, snacks were seen being delivered to the nurse's station but not distributed to residents. A resident was observed removing the plastic wrap and touching multiple snack bars on the cart while staff were present, raising concerns about food safety. Another resident requested a snack from a CNA, who attempted to provide it but was informed that the snacks had been touched by another resident. The dietary manager confirmed that while the kitchen provides snacks, they are only placed at the nurse's station and not delivered to residents, indicating a lack of clear responsibility for snack distribution.
Improper Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage practices within the facility's kitchen. The walk-in freezer had condensation and ice build-up on the ceiling and floor, with boxes of food placed directly on the iced floor. Additionally, the walk-in refrigerator contained a closed medication box and an unopened bottle of cola, both identified as belonging to a dietary staff member. The dietary manager confirmed that these personal items should not have been stored in the kitchen refrigerator, as there is a designated employee refrigerator for such items. Further inspection revealed six large bundles of flowers stored in the walk-in refrigerator. Facility policies require all food and supply items to be stored at least six inches off the floor and prohibit employee food, fluids, and personal items from being stored in kitchen coolers, freezers, or dry storage. The FDA Food Code also mandates that food be protected from contamination by proper storage in clean, dry locations and away from potential sources of contamination. Administrative staff confirmed that kitchen coolers are to remain free from personal items, medications, and flowers, indicating that these observations were in direct violation of both facility policy and professional standards.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically sexual abuse, as evidenced by repeated incidents involving a resident with severe cognitive impairment who displayed inappropriate sexual behaviors towards other residents. The care plan for this resident acknowledged a history of inappropriate sexual advances and included interventions such as redirection, monitoring, and reporting new behaviors to a health care provider. Despite these interventions, the resident was involved in multiple incidents where he touched female residents inappropriately, including touching a resident's breast and rubbing another resident's upper thigh. These incidents were witnessed by staff, who intervened at the time, and were documented in the resident's progress notes and facility investigation reports. Interviews with female residents revealed that the inappropriate touching had occurred on more than one occasion, with some residents stating that the behavior had been ongoing for about a month. The facility's investigation and documentation did not recognize these behaviors as sexual abuse, nor did they update or implement additional interventions to prevent further occurrences. The affected residents, including one with dementia and memory problems, were vulnerable due to their cognitive impairments. The facility's failure to identify and address the behaviors as sexual abuse resulted in a deficiency related to protecting residents from abuse.
Failure to Report Resident-to-Resident Sexual Abuse Incidents
Penalty
Summary
The facility failed to report incidents of resident-to-resident sexual abuse to the State Survey Agency as required by policy. Specifically, a resident with severe cognitive impairment was documented in the medical record and care plan as having displayed inappropriate sexual advances toward another resident. Progress notes detailed two separate incidents in which the resident was observed touching or rubbing a female resident's leg and upper thigh. In both cases, staff intervened, separated the residents, and provided education to the resident involved. Despite these documented incidents, there was no evidence that the facility reported the events to the State Survey Agency. The facility's policy requires prompt reporting and investigation of all suspected or alleged abuse, including notification of designated agencies. During staff interviews, it was revealed that supervisory staff were not informed of at least one of the incidents, further contributing to the failure to report as required.
Inaccurate MDS Coding for Diagnoses and Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident with a history of benign prostatic hyperplasia (BPH) and a chronic indwelling Foley catheter, the annual MDS identified the presence of the catheter but did not indicate the related diagnosis of BPH or urinary obstruction, despite documentation in the medical record and care plan. An MDS nurse confirmed that staff did not code the relevant diagnoses on the MDS. Additionally, two other residents who were prescribed and administered daily aspirin, an antiplatelet medication, were not coded for antiplatelet use on their quarterly MDS assessments. This omission was confirmed by an administrative staff member. The failure to accurately code both diagnoses and medication use on the MDS assessments means the residents' current statuses were not fully reflected in their assessments.
Failure to Develop Accurate Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to implement a baseline care plan that accurately reflected the immediate needs of a newly admitted resident. Record review showed that the resident had diagnoses of diabetes and hydrocephalus, with physician orders for Lantus Solo Star (insulin) for blood sugar management and Acetazolamide ER for obstructive hydrocephalus. The baseline care plan, however, incorrectly identified Acetazolamide as a treatment for diabetes, did not address the use of insulin, and omitted interventions for blood sugar irregularities. Additionally, the care plan failed to correctly identify the use of a diuretic and did not include interventions for complications related to hydrocephalus. During staff interviews, administrative staff confirmed that an accurate baseline care plan was not developed for the resident. The facility's policy required the use of pre-admission and admission information to develop an initial care plan with specific interventions, but this was not followed, resulting in a care plan that did not address the resident's actual clinical needs as documented in the medical record and physician orders.
Failure to Supervise Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to provide adequate supervision and enforce smoking policies for a resident who smoked, resulting in repeated incidents of smoking in unauthorized areas. The resident, who was assessed as safe to smoke independently and permitted to have two cigarettes at a time, was found smoking inside the building and in entryways on multiple occasions. Documentation showed that staff instructed the resident to use the designated outdoor smoking area, but the resident continued to smoke in prohibited locations, including inside the facility and just outside entry doors. The care plan required staff to check the resident for cigarettes and lighters upon return from smoking and to store these items at the nurse's station. Observations during the survey revealed that cigarettes and lighters were stored in an unlocked storage room in an open box, with the key left in the lock, contrary to facility policy. Interviews with staff indicated a lack of awareness and inconsistent enforcement of the policy requiring the box to be locked and the key kept in the nurse's medication cart. Administrative staff confirmed that the resident should not be smoking inside or near the building, and that the current storage practices for smoking materials did not align with facility expectations.
Failure to Provide Scheduled Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate toileting care for two residents who required staff assistance due to conditions such as multiple sclerosis and bipolar disorder. Both residents were identified as incontinent and had care plans specifying the need for scheduled toileting and assistance with incontinence care. Despite these care plans, observations revealed that staff did not consistently check or change the residents, encourage toileting, provide education, or notify nursing staff when residents refused care. For one resident with multiple sclerosis, staff offered toileting and repositioning multiple times, but the resident refused each time. However, the certified nurse aide did not check the resident's brief, encourage further toileting or repositioning, provide education about the importance of care, or notify the nurse of the refusals. Review of toileting records showed multiple instances where the resident was not checked, changed, or toileted for extended periods, including two days with no care for 24 hours and several days with only one or two checks in a 24-hour period. Another resident with bipolar disorder and impaired thought processes was observed with signs of soiling and a strong odor of feces, yet staff did not immediately provide care or notify nursing. The resident frequently refused toileting, and staff indicated that they would simply return later. Only after prompting from the surveyor did the CNA notify the nurse, who then provided the necessary assistance. The toileting record for this resident also showed several days with no checks or changes for 24 hours and many days with minimal care. Staff interviews confirmed that refusals were not consistently documented or reported to nursing as required.
Lack of Post-Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident receiving dialysis. According to facility policy, dialysis care should be individualized to the resident, including care planning for unique nutritional needs, fluid restrictions, and specific instructions such as avoiding blood pressure measurements and blood draws from the arm with a fistula. The resident in question had a care plan and nursing orders specifying the need for clinical monitoring before and after dialysis sessions, as well as instructions to monitor for signs and symptoms of complications such as bleeding, hemorrhage, and infection. Despite these requirements, the medical record did not contain documentation of communication from the dialysis unit regarding the resident's condition during and after dialysis treatments. Staff interviews confirmed that while information such as an order sheet, medication list, and care plan were sent with the resident to the dialysis facility, no handoff communication was received from the dialysis unit about the resident's status post-treatment. This lack of communication resulted in a failure to properly monitor and document the resident's condition as required.
Medication Error Rate Exceeds Five Percent Due to Improper Administration Practices
Penalty
Summary
Surveyors identified that the facility failed to maintain a medication error rate below five percent during medication administration observations. Specifically, out of 26 medications administered to five residents, four errors were observed, resulting in a fifteen percent error rate. For one resident, a medication aide crushed both a delayed-release calcium/magnesium supplement (Slow-Mag) and an extended-release Isosorbide Mononitrate tablet, despite facility policy and manufacturer instructions stating these medications should not be crushed. The aide placed the crushed medications into pudding and administered them to the resident. Additionally, a nurse was observed preparing insulin pens for two residents and failed to prime the pens correctly. Instead of holding the insulin pen with the needle pointing upwards as required by facility policy, the nurse primed the pens with the needle pointed down and dispensed the insulin into a sink. An administrative staff member confirmed that staff are expected to prime insulin pens vertically and not to crush delayed or extended-release medications.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the posting of accurate nurse staffing information on all four days of the survey, specifically from February 10 to February 13, 2025. Observations revealed that the Daily Staffing form, which was posted in the hallway by the residents' dining room, did not accurately reflect the number of unlicensed staff working each shift during this period. Review of the posted forms confirmed the inaccuracies, and during an interview, both an administrative nurse and the staffing scheduler acknowledged that the daily staffing forms were incorrect. No specific residents or patient medical histories were mentioned in relation to this deficiency. The deficiency was identified through direct observation, record review, and staff interviews.
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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