Good Samaritan Society - Oakes
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakes, North Dakota.
- Location
- 213 N 9th St, Oakes, North Dakota 58474
- CMS Provider Number
- 355095
- Inspections on file
- 23
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Good Samaritan Society - Oakes during CMS and state inspections, most recent first.
Two residents with severely impaired cognition, one with a documented history of inappropriate sexual behaviors, were involved in an incident of nonconsensual sexual contact after staff failed to provide adequate monitoring and timely psychiatric intervention, despite existing care plan interventions and known behavioral risks.
Facility staff did not report an incident of nonconsensual sexual contact between two residents, both with severely impaired cognition, to the State Survey Agency as required by policy. Administrative staff confirmed the failure to report the event, which involved one resident being found naked and straddling another resident with his hand in the other's brief.
Staff did not consistently assess, measure, or document pressure ulcers for two residents, including one with peripheral vascular disease and another with a sacral ulcer, as required by facility policy. Nursing staff interviews revealed confusion about wound assessment responsibilities and frequency, and an administrative nurse confirmed that weekly assessments were not always completed.
The facility failed to provide adequate nursing staff, resulting in reduced care and services for residents. A resident reported decreased bathing frequency and discontinued restorative therapy due to staffing shortages. Another resident experienced long wait times for toileting assistance, leading to an incident of incontinence. Family members expressed concerns about the impact of staffing reductions on resident care. An administrative staff member confirmed the decrease in staff and services.
The facility failed to follow infection control practices, including the use of Enhanced Barrier Precautions (EBP) and hand hygiene. Staff did not wear gowns during high-contact care for residents with conditions like surgical wounds and osteomyelitis, despite EBP requirements. Additionally, staff neglected hand hygiene protocols, such as washing hands before donning gloves and between assisting different residents.
A resident expressed a preference to use the toilet at night instead of a bedpan, but the facility required the use of a bedpan to avoid staffing two CNAs in the area. This decision did not respect the resident's dignity and worsened their back pain, highlighting a failure to provide individualized care.
A facility failed to provide a written bed hold notice to a resident or their representative during a hospital transfer, as required by policy. The policy mandates that written information be given at the time of transfer, detailing the duration of the state bed-hold policy, the reserve bed payment policy, and the facility's policies regarding bed-hold periods. A review of the medical record revealed a lack of documentation indicating that the required notice was provided, which was confirmed by an administrative staff member.
A resident experienced a significant decline in condition after a fall, resulting in increased dependency and incontinence. Despite these changes, the facility did not complete a required significant change in status assessment (SCSA) as outlined in the RAI 3.0 User's Manual.
The facility failed to accurately code the MDS for three residents, leading to discrepancies between the MDS and medical records. One resident's MDS incorrectly indicated independence in walking and required assistance for oral hygiene, while another resident's MDS inaccurately reflected the use of an antianxiety medication instead of an antipsychotic. A third resident's MDS incorrectly showed the use of a diuretic. These errors were confirmed by staff.
A facility failed to refer a resident for dental services within the required timeframe after the resident lost their bottom denture. The facility also did not assess the resident's ability to eat and drink adequately without the denture. The resident reported the loss and suspected it might have been accidentally discarded, leading them to eat soft foods.
The facility did not post daily staffing data for all shifts on 9 of 11 days reviewed, affecting transparency about staff on duty. An administrative staff member confirmed the oversight during an interview.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from nonconsensual sexual contact, resulting in a deficiency related to abuse prevention. According to the report, one resident with a diagnosis of Alzheimer's disease and severely impaired cognition was found in another resident's room. The second resident, also with severely impaired cognition and a documented history of inappropriate sexual behaviors, was observed naked and straddling the first resident, with his hand inside her brief. Staff discovered the incident when a registered nurse and a certified nurse aide were searching for the first resident, who was known to wander into other rooms. Prior to the incident, the care plan for the resident with a history of inappropriate sexual behaviors included interventions such as observing interactions with female residents, separating residents if necessary, and providing supervised socialization. There was also documentation of recent increased sexualized behaviors, including exposing genitalia and fondling himself in front of staff. A request for psychiatric evaluation had been made due to these behaviors, but the psychiatric visit did not occur until after the incident. The facility's policy stated that residents must not be subjected to abuse by other residents. Despite this, the interventions in place were not sufficient to prevent the incident of nonconsensual sexual contact. The failure to implement effective monitoring and timely psychiatric intervention contributed to the occurrence of abuse between the two residents, both of whom had severely impaired cognition and were vulnerable to such incidents.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
Facility staff failed to report an incident of resident-to-resident sexual abuse to the State Survey Agency as required by facility policy. The incident involved two residents, both with severely impaired cognition as identified in their admission Minimum Data Sets. One resident with Alzheimer's disease and psychotic disturbance was found fully clothed on a bed in another resident's room, while the other resident was naked, straddling the first resident, and had his hand in the other's brief. Despite the facility's policy mandating immediate reporting of alleged or suspected abuse to designated agencies, including the State Survey and Certification Agency, administrative staff confirmed that the incident was not reported.
Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
Facility staff failed to provide necessary care and services for two residents with pressure ulcers by not consistently assessing, measuring, and documenting the progression of their wounds as required by facility policy. For one resident with peripheral vascular disease and a right heel pressure ulcer, staff did not measure the ulcer or consistently document wound characteristics over a period of several months. For another resident with a sacral pressure ulcer present from admission until discharge, staff failed to measure the wound at least weekly, with multiple weeks lacking any recorded measurements. Interviews with nursing staff revealed a lack of clarity regarding responsibility and frequency for wound measurement and documentation. Some nurses were unsure of the required frequency for wound assessments, and there was inconsistency in understanding whether registered nurses or licensed practical nurses should perform these tasks. An administrative nurse confirmed that staff are expected to assess and measure pressure ulcers weekly, but acknowledged that this was not always being completed.
Insufficient Staffing Leads to Reduced Care and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of four residents and their family members. Resident A, who has intact cognition and requires restorative intervention for limited mobility, reported a reduction in bathing frequency from twice to once per week and the discontinuation of restorative therapy, which was previously provided every other day. The resident expressed that these changes were due to insufficient staffing. Similarly, a family member of Resident C expressed concerns about inadequate staffing, leading to situations where the resident had to remain in soiled conditions for extended periods. Resident D, who also requires restorative intervention due to ADL self-care performance deficits, experienced a similar reduction in bathing frequency and the cessation of the restorative therapy program. A family member of Resident D confirmed that these changes were attributed to staffing shortages. Additionally, Resident B, with intact cognition and requiring toileting assistance, reported long wait times for assistance, resulting in an incident where the resident was unable to reach the bathroom in time. An administrative staff member confirmed that staffing levels were reduced, leading to decreased bathing frequency and the discontinuation of the restorative therapy program.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control practices for several residents, specifically in the use of Enhanced Barrier Precautions (EBP) and hand hygiene. Observations revealed that staff did not wear gowns during high-contact care activities for residents requiring EBP due to conditions such as surgical wounds and osteomyelitis. For instance, staff members were observed transferring residents and providing toileting care without wearing the necessary gowns, despite clear indications on the residents' doors and care plans that EBP was required. Additionally, the facility's staff did not consistently perform hand hygiene as per the facility's policy. Observations showed that staff donned gloves without completing hand hygiene upon entering residents' rooms and failed to perform hand hygiene between assisting different residents with personal care tasks, such as providing fluids. These lapses in infection control practices were acknowledged by the staff involved and were contrary to the facility's stated policies on hand hygiene and EBP.
Failure to Honor Resident's Nighttime Toileting Preferences
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination by not accommodating their nighttime toileting preferences. The resident, who uses a sit-to-stand lift during the day and evening, expressed a preference to use the toilet at night instead of a bedpan. However, the facility required the resident to use a bedpan from 10:00 p.m. to 6:00 a.m. to avoid having two CNAs on duty in that area. The resident reported that using the bedpan exacerbated their back pain, indicating a lack of individualized care and respect for the resident's dignity and personal needs.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative during a hospital transfer, as required by their policy. The policy, dated December 7, 2023, mandates that written information be given at the time of transfer, detailing the duration of the state bed-hold policy, the reserve bed payment policy, and the facility's policies regarding bed-hold periods. A review of the medical record for Resident #35, who was transferred to a hospital on June 12, 2024, revealed a lack of documentation indicating that the required notice was provided. An administrative staff member confirmed this oversight during an interview on October 2, 2024.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) for a resident who experienced a significant change in condition. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, a significant change is defined as a major decline or improvement in a resident's status that impacts more than one area of health and requires interdisciplinary review and care plan revision. The manual specifies that a SCSA is necessary if there are two or more areas of decline or improvement. The resident in question experienced a fall resulting in a right lower leg fracture and subsequent hospitalization, which led to a decline in their activities of daily living (ADLs). Prior to the fall, the resident was independent in ambulation and personal hygiene, among other activities, and was always continent of bowel and bladder. After the fall and hospitalization, the resident became unable to ambulate, required a wheelchair, and was frequently incontinent. They also became dependent on staff for lower body dressing and required substantial assistance with personal hygiene and other ADLs. Despite these significant changes, the facility's records did not show evidence that staff identified the need for or completed a SCSA following the resident's decline.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which affected the accuracy of their assessments and potentially the development of their care plans. For one resident, the MDS inaccurately indicated that the resident required only setup or cleanup assistance for oral hygiene and was independent in walking, whereas the medical record showed the resident required partial/moderate assistance for these activities. This discrepancy was confirmed by an administrative staff member during the survey. Another resident's MDS incorrectly coded the use of an antianxiety medication, while the medication administration record (MAR) indicated the resident received an antipsychotic medication during the look-back period. Similarly, a third resident's MDS inaccurately reflected the use of a diuretic medication, which was not supported by the MAR. These errors were also confirmed by an administrative staff member, highlighting the facility's failure to accurately complete the MDS for these residents.
Failure to Provide Timely Dental Services for Lost Denture
Penalty
Summary
The facility failed to assist in obtaining dental services for a resident who lost their bottom denture. According to the facility's policy, a referral for dental services should occur within three days of discovering a lost or damaged denture. However, the facility did not refer the resident for dental services within this timeframe. Additionally, the facility did not assess the resident's ability to eat and drink adequately without the bottom denture. The resident reported missing the denture and expressed concern that it might have been accidentally discarded. The resident also mentioned eating soft foods due to the absence of the denture.
Failure to Post Daily Staffing Data
Penalty
Summary
The facility failed to post daily staffing data for all shifts on 9 out of 11 days reviewed, specifically from September 22 to October 2, 2024. This deficiency was identified through a review of the daily staffing information and the nursing staff schedule, which revealed that the number of staff working was not posted for nine day shifts, two evening shifts, and five night shifts. An administrative staff member confirmed during an interview on October 3, 2024, that the staffing data was not posted for each shift on some days. This failure to post accurate staffing data prevents residents and visitors from being aware of the number of licensed and unlicensed staff on duty for each shift.
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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