Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Park River during CMS and state inspections, most recent first.
A resident with dementia and behavioral disturbances engaged in sexually inappropriate behaviors toward another resident in a common area, including unwanted touching and exposure. Staff intervened during the incidents, but the facility failed to ensure residents remained free from abuse as required by policy.
Multiple residents and family members reported significant delays in call light response, with some waiting up to an hour for assistance and experiencing incontinence as a result. Call light logs and staff interviews confirmed frequent staffing shortages and prolonged response times, with administration aware of the ongoing issues. These deficiencies affected both resident care and dining assistance.
Surveyors found that kitchen and nutrition center areas were not maintained in a clean and sanitary manner, with accumulations of dirt, debris, sticky substances, food residue, and mold observed on various surfaces and equipment. Multiple open, unlabeled, and undated food items were found in freezers, and improper storage practices were noted, such as a gel ice pack stored next to ice cream. These findings were confirmed by dietary staff and were not in compliance with professional standards and facility policy.
The facility did not update care plans for two residents to reflect their current needs: one was transferred using a sit-to-stand lift despite the care plan specifying a pivot transfer with a gait belt, and another experienced significant weight loss without the care plan including specific interventions or goals. This failure limited staff communication and continuity of care.
Unsafe Sit-to-Stand Lift Transfer: A resident with muscle weakness and orthopedic pain was transferred by a CNA using a sit-to-stand lift without the shin/calf strap or proper shin support. The care plan did not address the strap need, and during the transfer the resident's legs shifted and buckled while the hands failed to grip the handlebars and the arms/elbows pushed outward and upward. The CNA did not notify the nurse of the unsafe transfer.
Expired medications were found in two medication storage areas, including the 100-200 Wing med cart and the med storage room. Items observed included saline solution laxatives, antimicrobial skin wound gels, antiseptic liquid for skin wounds, and nystatin powder that had passed their expiration dates. An administrative nurse confirmed expired meds should be discarded and not used.
The facility failed to assist two residents with activities of daily living (ADLs). One resident, admitted with a self-care performance deficit, experienced significant delays in receiving assistance with bed mobility, with gaps of up to 11 hours between interventions. Another resident, requiring help with personal hygiene, was observed with uncombed hair, dirty fingernails, and a soiled shirt, indicating inadequate care. These deficiencies highlight a failure to adhere to the facility's ADL policy.
The facility failed to provide timely toileting assistance for three residents, leading to potential risks for skin breakdown and poor hygiene. A resident was not assisted for up to 11 hours, contrary to their care plan. Another resident was found with a saturated incontinent product, and a third was not offered assistance when transferred. These actions did not meet the care plans' requirements.
A facility failed to follow its infection control policy when CNAs did not change gloves or perform hand hygiene between tasks while caring for a resident dependent on staff for toilet hygiene. This breach in protocol was confirmed by an administrative nurse, highlighting a potential risk for infection spread.
The facility failed to accurately code the MDS for several residents, leading to missing information about their functional abilities and nutritional needs. This included residents with conditions such as hemiplegia, Parkinson's disease, and those requiring feeding tubes. These inaccuracies were confirmed by staff during the survey.
The facility failed to notify physicians of critical blood sugar levels for two residents with diabetes. One resident had blood sugar levels exceeding the physician's threshold, while another experienced dangerously low levels, leading to an emergency room transfer. This lack of communication with physicians resulted in a deficiency.
A facility failed to ensure a resident and/or their representative completed the SNFABN upon discharge from Medicare Part A, limiting their ability to exercise rights regarding services. The SNFABN did not indicate choices about continuing services or requesting a demand bill, and there was no documentation that the resident or representative was informed of billing options.
The facility failed to update care plans for two residents, impacting communication and care continuity. One resident's care plan did not reflect the need for assistance with various ADLs, while another's did not include the use of a fall mat despite its documented necessity. These discrepancies were confirmed by administrative staff.
A facility failed to apply a leg strap during a sit-to-stand lift transfer for a resident with hemiplegia and hemiparesis, as required by the care plan. The CNA did not follow the care plan, which specified the use of a leg strap for safe transfers. An administrative staff member confirmed the oversight, highlighting a lapse in adherence to the facility's safe resident handling policy.
A facility failed to maintain a medication error rate below five percent, with two errors occurring during the administration of 25 medications. A nurse incorrectly primed insulin pens and removed the needle too quickly, potentially resulting in a resident receiving an incomplete dose.
The facility failed to ensure proper labeling of insulin pens during medication administration. A nurse prepared a Humalog insulin pen for a resident without a label or open date, and another resident's Tresiba pen also lacked an open date. Facility policy requires insulin pens to be labeled with the resident's name and open date, which was not followed.
The facility did not follow infection control standards for two residents requiring Enhanced Barrier Precautions due to indwelling medical devices. A nurse and two CNAs failed to wear gowns during high-contact care activities, despite the facility's policy requiring such precautions to prevent the spread of MDROs.
Staff members were observed conversing amongst themselves without engaging with residents, and a CNA was seen pounding on a table and addressing a resident loudly. Resident grievances highlighted staff attitudes as discouraging and unapproachable, impacting residents' sense of respect and value. These actions did not align with the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights.
The facility experienced delays in responding to call lights for four residents requiring staff assistance. Observations noted extended wait times, such as a 21-minute delay for Resident C's toileting needs and a 74-minute delay for Resident D. Interviews with residents highlighted concerns about inconsistent response times, with some waiting 30 minutes or longer. Call light logs from February confirmed significant delays in response times.
The facility failed to ensure a resident's call light was within reach after care was provided. A CNA assisted the resident into a recliner and left the room without placing the call light within reach. The resident was observed multiple times with the call light out of reach, and an administrative staff member confirmed that staff are expected to ensure call lights are accessible before leaving the room.
A resident reported a missing jacket about a month ago but did not receive any follow-up or resolution from the facility. An administrative staff member confirmed that she failed to complete a missing item report, investigate the grievance, or follow up with the resident, violating the facility's grievance policy.
The facility failed to update the comprehensive care plans for two residents, one of whom refused to wear tubigrips due to circulation issues, and another who required cushioned boots and bed and chair alarms for safety. The care plans did not reflect these changes, limiting staff's ability to ensure continuity of care.
The facility failed to consistently apply pressure-relieving devices for a resident with pressure ulcers on both heels. Despite orders for continuous use of cushioned heel boots unless walking, the resident was observed multiple times without the boots. Interviews revealed a communication gap among staff regarding the resident's care requirements.
A facility failed to use a gait belt, lock wheelchair brakes, and ensure the chair alarm was in place during the transfer of a resident with a history of falls. The resident's medical record indicated previous falls, and the facility's policies on fall prevention and gait-transfer belt usage were not followed.
A facility failed to provide appropriate toileting and check and change care for a resident with dementia, weakness, and a stage 3 pressure ulcer. The resident's care plan required checks every 2-3 hours during the day, but records showed 43 instances of non-compliance, with gaps of 4 to 12 hours between checks.
A facility failed to follow infection control standards during incontinence care for a resident. The CNA did not apply a clean brief and used a skin cleansing wipe instead of a disinfectant wipe to clean feces off the resident's oxygen tubing. An administrative staff member confirmed the expected procedures were not followed.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and behavioral disturbances engaged in sexually inappropriate behaviors toward another resident. The incident took place in a common area, where the male resident, while in his wheelchair, approached a female resident who was also in a wheelchair. He lifted her blanket, raised her shirt, and inappropriately touched her breast, abdomen, and vaginal region. Staff intervened and separated the residents immediately upon noticing the event. The female resident, who had a BIMS score of 0, was unaware of the incident and showed no response when questioned. Following the initial incident, the same male resident was observed later that evening self-propelling in his wheelchair with his pants and protective underwear partially down, exposing himself to peers. Staff intervened by bringing him to his room, moving other residents away, and reminding him to stay covered. The facility's policies defined such actions as sexual abuse, specifically non-consensual sexual contact and unwanted intimate touching. The documentation and staff interviews confirmed that the facility failed to ensure residents remained free from abuse, as required by policy.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff and related services to meet the needs of residents, as evidenced by multiple reports of delayed call light responses and staff shortages. Review of the facility's call light policy indicated that staff are required to respond to call lights promptly, but interviews with residents and family members revealed that call lights often went unanswered for extended periods, sometimes up to an hour. Specific residents reported waiting 30 minutes or more for assistance, including while needing help in the bathroom, which resulted in at least one instance of urinary incontinence due to the delay. Family members also expressed concerns about the timeliness of staff response across various shifts. Review of call light logs confirmed these delays, showing multiple occasions where residents waited 25 minutes or longer for assistance, with the longest wait times exceeding 50 minutes. Staff interviews corroborated these findings, with several staff members stating that they worked short-staffed on most shifts and that administration was aware of the ongoing shortages. These staffing issues affected both resident care areas and the dining room, particularly with feeding assistance, and were confirmed by an administrative nurse who acknowledged the failure to answer call lights promptly.
Failure to Maintain Sanitary Food Storage and Preparation Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain cleanliness and proper food storage in both the main kitchen and nutrition center. Specific findings included accumulations of dirt, debris, and sticky substances on the kitchen floor, under the three-compartment sink, on the oven hood, cabinet doors, and within utensil drawers. Food residue was noted on the backsplash and walls behind the food preparation areas, and dried food particles were found on pan covers. The reach-in refrigeration unit contained visible food debris and a sticky dark pink substance, while the freezer had a large unopened bag of onion rings with significant ice buildup. The walk-in refrigerator showed grey-green mold on the condenser unit and debris on shelving, and the walk-in freezer contained multiple open, unlabeled, and undated bags of food items. Additionally, a ceiling fan in the dishwashing area had an accumulation of dust and hanging debris. In the nutrition freezer, a large blue gel ice pack was stored next to ice cream cups. During an interview, a dietary staff member confirmed the expectation that all kitchen areas should be cleaned and food should be stored properly. These observations were made in the presence of dietary staff and were in direct violation of both the 2022 FDA Food Code and the facility's own food preparation and sanitation policies.
Failure to Update and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans to accurately reflect the current status and needs of two residents. For one resident, staff were observed transferring the individual from a wheelchair to the bathroom using a sit-to-stand mechanical lift, while the care plan specified a pivot transfer with one staff assist using a gait belt. A staff nurse confirmed that the resident was being transferred with a sit-to-stand lift, indicating the care plan was not updated to match the resident's actual transfer method. For another resident who experienced a weight loss of more than 10% in one month, the care plan noted unplanned weight loss but did not specify the related factors, evidence, target weight range, or frequency of weighing, and lacked interventions and goals addressing the weight loss. These deficiencies limited staff communication and continuity of care for the affected residents.
Unsafe Sit-to-Stand Lift Transfer
Penalty
Summary
Failure to ensure adequate supervision and assistance during a sit-to-stand lift transfer was identified for one sampled resident. The resident had diagnoses of muscle weakness and orthopedic pain. The care plan stated the resident required staff assist of one for toileting and transfers with the stand lift, but it did not address the need for a shin strap. Facility policy titled Safe Resident Handling Equipment-Competency Validation Checklist stated staff should check the care plan or Kardex for the type of equipment to be used, the type and size of sling, and the amount of assistance required, and should use the shin/calf strap when directed by the care plan or location-specific procedure. During observation, a CNA transferred the resident from a wheelchair to the bathroom using the sit-to-stand mechanical lift but did not attach the leg strap or place the resident's shins against the shin rests. During the transfer, the resident's legs shifted and buckled, the hands failed to grip the handlebars, and the arms/elbows pushed outward and upward. The CNA did not apply the leg strap during the transfer and did not notify the nurse of the unsafe transfer. An administrative nurse later confirmed the resident transferred using a sit-to-stand lift and stated staff were expected to report any change in transfer status.
Expired Medications Found in Medication Storage Areas
Penalty
Summary
The facility failed to discard expired medications in 2 of 3 medication storage areas reviewed, including the 100-200 Wing medication cart and the medication storage room. Observation of the medication storage room found three saline solution laxatives expired in December 2024, two tubes of antimicrobial skin wound gels expired in November 2024, and one bottle of antiseptic liquid for skin wounds expired in March 2025. Observation of the 100-200 Wing medication cart found one bottle of nystatin powder expired in December 2024. During interview, an administrative nurse confirmed that expired medication should be discarded and not used.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were dependent on staff for personal hygiene and bed mobility. Resident #1, who was admitted with an ADL self-care performance deficit related to weakness, required assistance with bed mobility. However, the bed mobility/repositioning log indicated significant gaps in assistance, with intervals of 4.5 hours, almost 6 hours, and 11 hours between staff interventions. This lack of timely assistance occurred during the resident's brief stay, as the resident expired approximately 48 hours after admission. Resident #2, who also had an ADL self-care performance deficit, required assistance with personal hygiene. Observations revealed that the resident was left with uncombed hair, long, dirty fingernails, and was seen wearing a soiled shirt. These observations were made on two separate occasions, indicating a failure by the facility to provide adequate personal hygiene care. The facility's policy on ADLs, which mandates necessary services to maintain grooming and personal hygiene for residents unable to perform these tasks independently, was not adhered to in these cases.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance for three residents who required staff assistance, leading to potential risks for skin breakdown, poor hygiene, and urinary tract infections. Resident #1, who was admitted shortly before passing away, was not assisted with toileting for extended periods, including a gap of 11 hours on one occasion. This lack of timely assistance was contrary to the resident's care plan, which required a full lift and two-person assist for toileting. Resident #4 was observed with a saturated incontinent product that leaked urine through their pants, indicating a delay in toileting assistance since the last recorded assistance was nearly three hours prior. Similarly, Resident #5, who required assistance with a gait belt for toileting, was not offered toileting assistance when transferred from a recliner to a wheelchair and then to the commons area. These observations and record reviews highlight the facility's failure to adhere to the residents' care plans and provide necessary toileting assistance, as confirmed by an administrative staff member's expectations.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding hand hygiene practices. During an observation, two certified nurses aides (CNAs) were seen assisting a resident who was dependent on staff for toilet hygiene. The CNAs donned gloves to transfer the resident using a sit-to-stand lift and performed various tasks, including cleaning the lift and changing the resident's brief. However, one of the CNAs did not change gloves or perform hand hygiene between tasks and after completing personal resident care, which is a violation of the facility's hand hygiene policy. The facility's hand hygiene policy, dated March 2022, requires health care workers to perform hand hygiene after glove removal and after contact with a patient's excretions. An administrative nurse confirmed that staff are expected to remove gloves and perform hand hygiene after perineal care. The failure to follow these standards has the potential to spread infection throughout the facility, as it was observed that the CNA continued to use the same gloves throughout the care process without performing hand hygiene.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for five residents, which is crucial for reflecting each resident's current status and needs. Specifically, the MDS for several residents contained dashes in Section GG, indicating missing information about their functional abilities and the assistance required. For instance, one resident with hemiplegia and hemiparesis had dashes in areas such as oral hygiene and transfers, while another resident with Parkinson's disease and dementia had missing data in areas like toileting hygiene and dressing. These omissions were acknowledged by an administrative nurse during the survey. Additionally, the facility did not accurately code the MDS for a resident with a feeding tube and a mechanically altered diet. The resident's MDS incorrectly identified only a therapeutic diet, omitting the presence of a feeding tube and the need for a mechanically altered diet. This discrepancy was confirmed by a dietary manager during the survey. These inaccuracies in MDS coding could potentially impact the development of comprehensive care plans and the care provided to the residents.
Failure to Notify Physician of Critical Blood Sugar Levels
Penalty
Summary
The facility failed to adhere to physician's orders regarding blood sugar monitoring for two residents, leading to a deficiency. Resident #17, diagnosed with type two diabetes mellitus, had specific orders to notify the physician if blood sugar levels exceeded 451 mg/dL. However, the facility did not inform the physician when Resident #17's blood sugar levels were recorded at 453 mg/dL and 458 mg/dL in January 2024. This oversight in communication could have prevented the physician from evaluating the need to adjust treatment. Similarly, Resident #86, also diagnosed with type two diabetes mellitus and experiencing hypoglycemia, had orders to notify the physician if blood sugar levels were below 70 mg/dL or above 400 mg/dL. The facility failed to notify the physician of low blood sugar readings of 67 mg/dL, 62 mg/dL, and 65 mg/dL on multiple occasions. This lack of communication resulted in Resident #86 being transferred to the emergency room after a critically low blood sugar reading of 42 mg/dL, which required emergency intervention with Glucagon.
Failure to Complete SNFABN for a Resident
Penalty
Summary
The facility failed to ensure that a resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for a resident discharged from Medicare Part A in the past six months. This failure limited the resident's or representative's ability to exercise their rights regarding Medicare Part A services. Specifically, the SNFABN did not indicate whether the resident or their representative chose to continue or discontinue services or request a demand bill. A review of the resident's medical record showed a lack of documentation indicating that the resident or their representative was informed of their options related to billing and services when Medicare Part A coverage ended. An administrative staff member confirmed that staff failed to document whether the resident and/or her representative were informed of their options related to billing and services when Medicare Part A coverage ended.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for two residents, leading to deficiencies in communication and continuity of care. For one resident, the care plan inaccurately stated that the resident only required assistance with bathing, while a recent Minimum Data Set (MDS) indicated the need for setup or cleanup assistance for eating and partial/moderate staff assistance for various activities of daily living (ADLs) such as oral hygiene, toileting hygiene, dressing, and personal hygiene. This discrepancy was confirmed by an administrative staff member during an interview, highlighting the failure to reflect the resident's current care needs in the care plan. Another resident's care plan did not address the use of a fall mat at the bedside, despite multiple progress notes and observations indicating its presence and necessity due to the resident's risk of falls related to osteoporosis and gait abnormalities. The care plan mentioned the resident's history of falls and a femur fracture but failed to incorporate the fall mat as a safety measure. This oversight was also confirmed by an administrative staff member, indicating a lack of updates to the care plan to ensure the resident's safety and care needs were adequately addressed.
Failure to Apply Leg Strap During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during a sit-to-stand lift transfer for a resident, leading to a repeat deficiency. The deficiency was identified during an observation where a certified nurse aide (CNA) transferred a resident from the bed to the toilet using a sit-to-stand lift without applying the leg strap as required by the resident's care plan. The care plan specified the use of a sit-to-stand lift with a medium sling and leg strap, with assistance from one staff member for transfers. However, the CNA did not apply the leg strap during the transfer process, which was a deviation from the care plan. The resident involved had a medical history that included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle spasm, and polyneuropathy. These conditions necessitated the use of specific transfer equipment and procedures to ensure safety. The facility's policy on safe resident handling required checking the care plan for equipment type and the application of a shin/calf strap when additional lower extremity support was needed. An administrative staff member confirmed that the leg strap should have been applied as per the care plan, indicating a lapse in following established procedures.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration for one of the seven residents observed. Specifically, two medication errors occurred during the administration of 25 medications, resulting in an eight percent error rate. The errors were observed during the administration of insulin to a resident. A nurse prepared a Levemir insulin pen and a Fiasp insulin pen but did not follow the facility's policy for insulin administration. The nurse primed the insulin pens incorrectly by holding them horizontally instead of vertically and removed the needle from the skin immediately after injection, which may have resulted in the resident receiving less than the full dose of insulin.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure accurate labeling of medications, specifically insulin pens, during medication administration. During an observation, a nurse prepared a Humalog insulin pen for a resident without a label containing the resident's name or other identifying information, and it also lacked an open date. Additionally, another insulin pen, Tresiba, for a different resident, was found without an open date during a check of the medication cart. The facility's policy requires insulin pens to be clearly labeled with the resident's name or other identifiers and to have an open date, which was not adhered to in these instances. A nurse confirmed that whoever opens a pen is supposed to date it when opened.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling medical devices. For Resident #1, who had a gastrostomy tube, a nurse performed necessary medical procedures such as flushing the feeding tube and changing the dressing at the tube site. Although the nurse followed hand hygiene and glove protocols, they did not wear a gown as mandated by the facility's policy for EBP, which is crucial to prevent the spread of multi-drug resistant organisms (MDROs). Similarly, Resident #3, who had a suprapubic catheter, was involved in exercises with a restorative nursing aide and later had their catheter bag emptied by two certified nurse aides. In both instances, the staff members failed to don gowns, which is a requirement when performing high-contact care activities under EBP. The administrative staff confirmed that the staff should have worn the appropriate personal protective equipment (PPE) as per the facility's infection control policy.
Deficiency in Resident Respect and Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by staff members conversing amongst themselves without interacting with residents during observation on 03/12/24 at 8:05 a.m. Additionally, an unidentified CNA was observed pounding on the table and addressing a resident in a loud and potentially disrespectful manner, indicating a lack of courteous and dignified communication. The grievances filed by residents further highlighted instances where staff attitudes were perceived as discouraging, unapproachable, and unpleasant, creating an environment where residents did not feel respected or valued. The failure to promote resident dignity and self-determination was underscored by the lack of respectful interactions and communication observed during the survey. Instances where residents felt staff attitudes were negative and unwelcoming further emphasized the impact of such behavior on residents' psychosocial wellbeing. The facility's obligation to treat residents with courtesy, fairness, and dignity, as outlined in the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, was not consistently upheld based on the observations and grievances documented during the survey.
Delayed Response to Residents' Call Lights
Penalty
Summary
The facility failed to promptly respond to residents' call lights for four confidential residents (Residents A, B, C, and D) who required staff assistance. Observations revealed instances where residents had to wait an extended period before receiving assistance after activating their call lights. For example, Resident C had to wait 21 minutes before receiving help with toileting needs after activating the call light. Additionally, during interviews, residents expressed concerns about inconsistent response times, with Resident A mentioning waiting for 30 minutes or longer for assistance at times. Further review of the facility's call light logs from specific dates in February showed significant delays in responding to residents' call lights. For instance, Resident D had to wait 74 minutes for assistance after activating the call light on 02/03/24.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodation of needs regarding call lights for one resident. Observations showed that a CNA completed cares, assisted the resident into a recliner, and exited the room without placing the call light within the resident's reach. The resident was observed multiple times over a span of 38 minutes with the call light out of reach. An administrative staff member confirmed that staff are expected to ensure all residents' call lights are within their reach before exiting the room.
Failure to Implement Effective Grievance System
Penalty
Summary
The facility failed to implement an effective grievance system for a resident who reported a missing jacket. The facility's policy on grievances, dated November 2023, requires documentation, investigation, and follow-up for any grievances reported. However, the facility did not adhere to this policy in the case of Resident #3. The resident reported the missing jacket about a month ago but did not receive any follow-up or resolution from the facility. An administrative staff member confirmed that the resident had informed her of the missing jacket, but she failed to complete a missing item report, investigate the grievance, or follow up with the resident. This lack of action resulted in the facility not honoring the resident's right to voice grievances without discrimination or reprisal, as required by their own policy.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents, which limited staff's ability to communicate needs and ensure continuity of care. For Resident #1, the care plan included instructions to apply and remove tubigrips to the lower extremities. However, during an interview, the resident reported that she no longer wears the tubigrips because they cut off her circulation and she did not like them. The facility did not update the care plan to reflect the resident's refusal to wear the tubigrips. For Resident #2, the medical record indicated diagnoses of unspecified stage ulcers to the left and right heels and repeated falls. A provider order required the resident to wear cushioned boots continuously unless walking. Additionally, nursing progress notes indicated the use of bed and chair alarms for the resident's safety. However, the care plan did not include the use of cushioned boots and bed and chair alarms. The facility's failure to update the care plans for these residents did not reflect their current status and needs.
Failure to Consistently Apply Pressure-Relieving Devices
Penalty
Summary
The facility failed to provide care and services to promote the healing or prevent the development of pressure ulcers for a resident with current pressure ulcers on both heels. The facility's policy required the use of cushioned heel boots to elevate the heels off the bed, but this intervention was not consistently applied. The resident's medical record included orders for the continuous use of cushioned heel boots unless walking, but these orders were not reflected in the Medication Administration Record (MAR), Treatment Administration Record (TAR), or care plan. Observations showed multiple instances where the resident was either in a wheelchair or resting in a recliner without the cushioned boots in place. Even after a nurse instructed a CNA to place the boots on the resident's feet, the boots were removed and not reapplied when the resident was transferred to a wheelchair for lunch. Interviews with CNAs revealed a lack of awareness about the resident's need for cushioned heel boots, indicating a communication gap among staff. The CNAs relied on charting screens and communication with other staff or the residents themselves to understand care requirements. This lack of consistent application of pressure-relieving devices as ordered could lead to the deterioration of existing pressure ulcers and delayed healing for the resident.
Failure to Use Assistive Devices and Ensure Chair Alarm Placement
Penalty
Summary
The facility failed to use an assistive device necessary to safely transfer a resident and ensure the chair alarm was in place to prevent accidents. Specifically, a certified nurse aide (CNA) assisted Resident #2 from a wheelchair to a standing position without using a gait belt and without locking the wheelchair brakes. During the transfer, the wheelchair rolled back as the resident sat down. Additionally, the chair alarm pad was observed lying on the floor beside the resident's recliner and was not placed back by the CNA after completing the incontinent cares. Resident #2's medical record indicated a history of falls related to abnormalities of gait and mobility, anxiety, weakness, and impulsiveness. The resident had previously fallen and was found with blood spots in his room, and the chair alarm was on the floor next to his recliner. The facility's policies on fall prevention and gait-transfer belt usage were not followed, as the CNA did not use a gait belt, lock the wheelchair brakes, or place the chair alarm pad as required. An administrative nurse confirmed that staff are expected to follow these procedures to ensure resident safety.
Failure to Provide Appropriate Toileting and Check and Change Care
Penalty
Summary
The facility failed to provide appropriate toileting and check and change care for a resident who required staff assistance with toileting. The resident, who had diagnoses of dementia, weakness, abnormalities of gait and mobility, and repeated falls, was care planned to be checked and reminded to toilet every 2-3 hours during the day and allowed to sleep undisturbed for at least 4 hours at night. However, a review of the resident's toileting record from February 12, 2024, to March 12, 2024, identified 43 occasions where staff did not follow the care plan, with gaps of approximately 4 to 12 hours between checks and changes. The resident also had a physician's order for a Mepilex dressing to the coccyx, which needed to be changed daily and checked as needed to avoid stool underneath the dressing due to a stage 3 pressure ulcer on the left buttock. The failure to adhere to the care plan and physician's orders was confirmed during an interview with an administrative staff member, who stated that she expected staff to provide toileting and check and change care to all residents as per their care plans.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to follow infection control standards during incontinence care for a resident. The resident, who was seated in a wheelchair and wearing a nasal cannula attached to an oxygen concentrator, was assisted by a CNA to a standing position for incontinence care. During the process, the resident's oxygen tubing and the outside of the clean brief came into contact with feces present on a disposable pad on the wheelchair seat. The CNA did not apply a clean brief and instead pulled up the resident's pants and transferred him into a recliner. Additionally, the CNA used a skin cleansing wipe, not a disinfectant wipe, to clean the feces off the resident's oxygen tubing. An administrative staff member later confirmed that the CNA should have changed the soiled incontinence product and disinfected or replaced the contaminated oxygen tubing. The failure to follow these infection control standards was observed and documented, highlighting a lapse in proper infection prevention protocols within the facility.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Park River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Sunset Home | 18.7 mi | ★★★★★ | 8 | 0 |
| Wedgewood Manor | 30.9 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Larimore | 32.5 mi | — | 28 | 0 |
| Good Samaritan Society - Lakota | 33.5 mi | ★★★★★ | 0 | 0 |
| Maple Manor Care Center | 38.5 mi | ★★★★★ | 9 | 0 |
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