Knife River Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beulah, North Dakota.
- Location
- 118 22nd St Ne, Beulah, North Dakota 58523
- CMS Provider Number
- 355053
- Inspections on file
- 24
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Knife River Care Center during CMS and state inspections, most recent first.
A resident with a known risk for elopement, documented wandering behaviors, and a functioning wander guard was able to exit the facility unsupervised. Although the door alarm was triggered and sent to staff walkie-talkies, staff did not respond promptly, allowing the resident to remain outside for several minutes before being returned by an employee who found them in the parking lot.
Surveyors found that two residents who used wheelchairs were affected by the facility's failure to maintain clean and safe equipment and living areas. One resident's wheelchair had damaged armrest pads, while another's Broda chair was observed with dried feces and food debris, and cleaning logs showed missed scheduled cleanings. Staff and family interviews confirmed these deficiencies.
A CNA transferred a resident with significant mobility limitations using a ceiling lift but failed to use the required cross-through method for the sling straps, as outlined in the manufacturer's instructions. This deviation from protocol during the transfer process resulted in inadequate assistance and supervision, increasing the risk of fall and injury for the resident.
A resident in a memory care unit was found on the floor being kicked by another resident in a wheelchair. Both residents had severely impaired cognition and histories of aggressive behavior related to dementia. The incident was discovered by two staff nurses who intervened to ensure the safety of the resident on the floor. The facility's policy prohibits abuse by anyone, including other residents, but this incident demonstrated a failure to maintain a safe environment.
A facility failed to update a resident's care plan to reflect their history of suicidal ideation, despite multiple documented instances of concerning behavior, including striking another resident and expressing suicidal thoughts. This oversight limited staff's ability to communicate the resident's needs and ensure continuity of care.
A resident with severely impaired cognition experienced physical abuse by a family member, who was observed gripping the resident's arm and slapping them. The facility failed to promptly investigate the incident or document the resident's injuries, including bruising and a dislocated finger, until two days later.
A resident with severely impaired cognition was physically abused by her daughter, who was reported to have slapped her. Although a nurse intervened and asked the daughter to leave, the facility failed to report the incident to the SSA within the required 2 to 24-hour timeframe, as confirmed by administrative staff.
A resident sustained burns from hot coffee after falling asleep at a table, highlighting the facility's failure to monitor beverage temperatures and provide mug lids as per the care plan. The resident had a history of spilling hot liquids, yet the care plan did not include necessary precautions. Temperature readings showed beverages were served at unsafe temperatures, and staff confirmed the lack of monitoring, leading to the incident.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility unsupervised. The resident had a history of wandering, was disoriented to place, and had impaired safety awareness, as documented in quarterly elopement assessments and the care plan. The care plan included interventions such as the use of a wander guard, structured activities, and frequent checks, but these measures were not sufficient to prevent the resident from exiting the building. On the day of the incident, the resident was found outside in the facility's parking lot by an employee, fully dressed and sitting in a wheelchair, attempting to get into a parked car. The wander guard device was in place and appeared to be functioning, and the door alarm was triggered and sent to staff walkie-talkies. However, staff did not respond to the alarm in a timely manner, allowing the resident to remain outside for approximately five minutes before being returned to the building by a staff member who recognized the resident in the parking lot. Review of camera footage confirmed that the resident was able to hold the door to disarm the locking system and exit the facility. The incident lasted about ten minutes, with the resident outside for half of that time. Documentation and interviews confirmed that the alarm system was operational, but the lack of immediate staff response to the alarm resulted in the resident's unsupervised elopement.
Failure to Maintain Clean and Safe Wheelchairs and Resident Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for two residents who required wheelchairs. One resident's wheelchair was found in disrepair, with cracked, missing, and flaking vinyl on the armrest pads. A staff member confirmed that the armrest pads needed replacement. For another resident, a family member reported that staff did not clean the resident's Broda chair or room, pointing out tissues, a lollipop stick on the floor, and dried feces on the chair's frame. Observations confirmed the presence of dried feces and food debris in various parts of the chair, and a CNA acknowledged the need for cleaning. Review of the facility's cleaning logs revealed that the Broda chair was scheduled for weekly cleaning, but staff failed to sign off on this task for seven out of twelve scheduled weeks. An administrative nurse stated that she expected staff to clean the wheelchairs weekly as scheduled. These findings demonstrate that the facility did not ensure regular cleaning and maintenance of equipment and resident areas as required.
Improper Use of Ceiling Lift Sling During Resident Transfer
Penalty
Summary
A certified nurse aide (CNA) transferred a resident with limited physical mobility, contractures, and muscle weakness from a wheelchair to a bed using a ceiling lift. During the transfer, the CNA attached the leg strap loops of the sling to the spreader bar but did not use the cross-through method as specified in the manufacturer's instructions for the Maxi Sky 2 ceiling lift. The resident's care plan required the use of a ceiling track for transfers due to their physical limitations. A nursing supervisor confirmed that the cross-through method should have been used, particularly for this resident given their muscle weakness. This failure to follow the proper sling strap method during the ceiling lift transfer resulted in inadequate assistance and supervision, placing the resident at risk for a fall and injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents in the memory care unit. On the specified date, two staff nurses heard moaning and discovered one resident lying on the floor while another resident, seated in a wheelchair, was kicking the resident on the floor. The resident in the wheelchair was known to have severely impaired cognition and a history of aggressive behavior related to dementia and childhood trauma. The resident on the floor also had severely impaired cognition and was identified as a wanderer with potential for verbal and physical aggression due to dementia. The incident was documented in the progress notes, indicating that the resident on the floor was assessed and found to have no injuries, and both family and providers were updated. The facility's policy on abuse prohibition clearly states that residents must not be subjected to abuse by anyone, including other residents. Despite this policy, the incident occurred, demonstrating a failure to ensure an environment free from abuse, which placed the involved resident and potentially others at risk for harm.
Failure to Update Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to review and revise the care plan for one of the sampled residents, which resulted in a deficiency. The medical record review for the resident revealed multiple instances of concerning behavior, including striking another resident, expressing suicidal ideation, and verbal agitation. Despite these documented behaviors, the resident's care plan did not include a history of suicidal ideation, which limited the staff's ability to communicate the resident's needs and ensure continuity of care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving the resident's daughter. The daughter was observed by an activity aide to have a firm grip on the resident's arm, causing discoloration, and subsequently slapped the resident across the face. The activity aide intervened by involving the charge nurse and removing the daughter from the situation. Despite the immediate intervention, the facility did not promptly investigate the incident or document the resident's condition, including bruising and a dislocated finger, until two days later. The resident involved had severely impaired cognition, as identified in their medical records. The lack of immediate investigation and documentation of the resident's injuries, such as bruising and a dislocated finger, highlights the facility's failure to ensure the resident's safety and protection from abuse. The medical record lacked documentation of the resident's skin condition, pain, or discomfort following the incident until after the resident returned from the emergency room two days later.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of physical abuse involving a resident to the State Survey Agency (SSA) within the required time frame. The incident involved a resident with severely impaired cognition, whose daughter was reported by the activities director to have been slapping the resident in the face. A nurse intervened by asking the daughter to leave the facility and informed her that abuse is not tolerated. Despite this immediate action, the facility did not report the incident to the SSA within the mandated 2 to 24-hour period. An administrative staff member confirmed that the charge nurse had informed them of the incident on the day it occurred, but the investigation and notification to the SSA were not initiated until two days later. This delay in reporting constitutes a failure to comply with regulations designed to protect residents from abuse. The facility's policy clearly outlines the requirement for immediate reporting of any alleged abuse to the appropriate authorities, which was not adhered to in this case.
Resident Burned by Hot Coffee Due to Lack of Temperature Monitoring
Penalty
Summary
The facility failed to ensure an environment free of accident hazards, resulting in a resident sustaining burns from hot coffee. The incident involved a resident who fell asleep at a table and spilled hot coffee on her lap, causing large areas of redness and blistering on her thighs. The resident's medical record indicated a history of risk for injury related to hot liquids, with previous incidents of spilling tea on herself. Despite this, the resident's care plan did not include a requirement for mug lids on the meal ticket or dietary care plan, and staff interviews confirmed that the tray provided to the resident lacked a lid on the hot beverage. Temperature readings taken during the investigation revealed that the coffee and hot water temperatures in various kitchenettes and machines were significantly above the safe serving temperature of 140 degrees Fahrenheit. The facility did not monitor the temperature of hot beverages before or on the day of the incident, which contributed to the resident's injury. Interviews with administrative and dietary staff confirmed the lack of temperature monitoring and the absence of mug lids, highlighting the facility's failure to prevent the accident hazard.
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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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