Minot Health And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Minot, North Dakota.
- Location
- 600 S Main St, Minot, North Dakota 58701
- CMS Provider Number
- 355031
- Inspections on file
- 25
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Minot Health And Rehab, Llc during CMS and state inspections, most recent first.
A resident with severe expressive aphasia and anxiety disorder, dependent on staff for toileting, was left on a bedside commode for approximately six hours without the call light within reach or regular checks by CNAs. This resulted in skin discoloration to the buttocks and a wrist bruise from attempting to get help, as the care plan requiring call light placement and monitoring was not followed.
A resident with severe expressive aphasia and dependent on staff for toileting was left on a bedside commode for an extended period, resulting in skin redness and a bruise from attempting to get help. The incident, which met the facility's criteria for reporting suspected neglect, was not reported to the State Survey Agency as required by policy.
Multiple failures were observed in maintaining a safe, clean, and homelike environment, including non-functioning lights, soiled privacy curtains, visible dust and debris, torn wallpaper, and makeshift repairs with tape. Staff interviews confirmed that cleaning and maintenance procedures were not consistently followed, and required reporting of maintenance issues was not always completed.
The facility did not provide required written transfer and bed-hold notices, including reserve bed payment information, to several residents or their representatives during hospital transfers, and failed to notify the State Long Term Care Ombudsman as required. Documentation reviews and staff interviews confirmed these omissions.
Surveyors found that the facility did not accurately code the MDS for several residents, including failing to document serious mental illness, hospice care, depression diagnosis, correct discharge location, and wound dressing treatments, despite supporting medical records and physician orders.
Facility staff did not transcribe a physician's order for multiple blood tests into the electronic medical record and did not ensure the collection of the required blood specimens for a resident. Administrative staff confirmed the omission, and there was no documentation that the laboratory tests were completed.
A resident dependent on staff for bathing did not consistently receive scheduled baths, as evidenced by unclean fingernails and incomplete documentation of bathing assistance. Family concerns and staff interviews confirmed lapses in both care provision and record-keeping.
Two residents receiving hospice services did not have the required hospice election forms in their medical records, despite documentation of hospice enrollment and admission. Facility policy and the hospice contract both require these forms to be obtained and maintained, but an administrative nurse confirmed their absence.
A staff member at the facility took inappropriate images and videos of residents, leading to a failure to protect them from sexual and mental abuse. This affected multiple residents, some with cognitive impairments. The facility's policies on abuse and social media use were not effectively enforced, resulting in an Immediate Jeopardy situation.
A resident with severely impaired cognition due to dementia and Parkinson's disease experienced non-consensual sexual contact from another cognitively intact resident. The incident was observed by a staff member, who reported that the affected resident appeared distressed and attempted to swat the other resident away. The facility's policy on abuse, neglect, and exploitation was not effectively implemented to prevent this incident.
A resident developed a stage IV pressure ulcer with exposed hardware due to the facility's failure to evaluate risk factors and implement necessary interventions. The resident, admitted post-surgery for a broken ankle, did not receive proper wound assessment and monitoring, leading to the ulcer's progression. Staff failed to document changes in the wound status and did not complete required assessments.
The facility failed to accurately code the MDS for several residents, affecting the accuracy of assessments and care plans. A resident with Bipolar II Disorder was not correctly coded in the PASRR section, while another resident's medication coding inaccurately reflected insulin use. Additionally, a resident's diuretic use was not recorded. These errors were confirmed by staff interviews.
The facility did not follow professional standards for insulin administration for two residents. A nurse failed to keep the needle in the skin for the required time after administering insulin, and another nurse did not prime an insulin pen according to policy. These actions could lead to inaccurate dosing.
A facility failed to ensure accurate labeling of insulin pens during medication administration for a resident. A nurse prepared insulin and removed a plastic bag labeled with the resident's name from the medication cart, containing NovoLog and Tresiba insulin pens. The NovoLog pen lacked a medication label with the resident's name and administration instructions, and the Tresiba pen lacked an open date. This was against the facility's policy, which requires documenting the open date on the pen body and verifying that the medication label matches the MAR. An administrative nurse confirmed the expectation for staff to follow this policy.
A facility failed to notify a resident's representative of care conferences and did not inform a physician about another resident's high blood sugar levels. The facility's policy requires notifying representatives and physicians of significant changes, but records showed no evidence of such notifications. Interviews confirmed these communication failures, which could prevent appropriate care planning.
Failure to Follow Care Plan for Toileting and Call Light Placement
Penalty
Summary
Staff failed to follow the care plan for a resident with severe expressive aphasia and anxiety disorder, who was dependent on staff for toileting. The care plan specifically required that the call light be secured to the bedside commode and within reach when the resident was toileting. On the evening in question, two certified nurse aides transferred the resident to the bedside commode but did not place the call light within reach and did not check on the resident for approximately six hours. As a result of these actions, the resident was found on the commode after an extended period, with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident, who was unable to verbalize needs due to aphasia, was left without a means to call for help and was not monitored as required by the care plan.
Failure to Report Suspected Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect to the State Survey Agency as required by its own policy and federal regulations. A resident with a history of anxiety disorder and severe expressive aphasia, who was dependent on staff for toileting, was found left on a bedside commode for an extended period of time. The care plan for this resident specified the need to ensure the call light was secured and within reach during toileting due to impaired communication. A progress note documented that the resident was found with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident denied pain and showed no signs or symptoms of pain at the time of assessment. Despite these findings, the facility did not report the incident to the State Survey Agency as required by their policy, which mandates immediate reporting of all alleged violations of abuse or neglect. An administrative nurse confirmed during an interview that the incident was not reported. The failure to report this incident constitutes a deficiency in the facility's compliance with abuse and neglect reporting requirements.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and homelike environment for residents. Observations revealed issues in several resident rooms, including a non-functioning bathroom light that had been out for about two weeks despite being reported to staff, visible dust and debris on ceiling vents, soiled wallpaper, torn wallpaper, and missing or broken equipment such as a thermostat and a ceiling light cover. Some rooms had makeshift repairs, such as masking or painter's tape with dried paint on doors and window screens with holes patched by residents themselves. In one case, a privacy curtain was visibly soiled with what a resident identified as blood, and the curtain had not been cleaned or replaced as required by facility policy. Interviews with staff confirmed that cleaning and maintenance procedures were not consistently followed. The housekeeping supervisor acknowledged that privacy curtains are supposed to be cleaned weekly and when visibly soiled, but confirmed that a soiled curtain remained in place. Administrative staff admitted that painter's tape was not removed in a timely manner and that maintenance concerns, such as missing light covers and non-functioning lights, were not reported as expected. The facility's own policies and housekeeping checklists require regular cleaning, spot-cleaning of walls, and prompt attention to visible dirt or damage, but these standards were not met in the sampled rooms and storage areas.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers and bed-hold policies for multiple residents who were hospitalized. Specifically, for four sampled residents and one closed record, the facility did not provide the residents or their representatives with written notices of transfer or bed-hold, nor did they notify the State Long Term Care Ombudsman as required. In several cases, the bed-hold notices that were provided lacked the required information about the reserve bed payment amount, and transfer notices did not show evidence of Ombudsman notification. These deficiencies were identified through record reviews, policy reviews, and staff interviews. The review of facility policies confirmed that written information regarding bed-hold practices and transfer notifications, including the reserve bed payment policy and Ombudsman notification, should be provided at the time of transfer for hospitalization. However, documentation for the sampled residents showed missing or incomplete notices for hospitalizations, with some records lacking any notice and others missing specific required details. An administrative nurse confirmed during interviews that the required documentation was not present in the records reviewed.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for several residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. Specific deficiencies included not identifying a serious mental illness for a resident with a qualifying PASRR Level II screening, incorrectly coding a resident's discharge location as a nursing home instead of home, and omitting an active diagnosis of depression for a resident receiving antidepressant medication. Additionally, a resident admitted to hospice care was not coded as terminally ill or as receiving hospice services on the MDS, and another resident's application of dressings to lower extremity wounds was not documented in the MDS despite treatment records confirming the care was provided. These inaccuracies in MDS coding were confirmed by an administrative nurse and were found across multiple sections, including identification information, active diagnoses, health conditions, skin conditions, and special treatments. The errors were substantiated by medical records, physician orders, treatment administration records, and progress notes, all of which demonstrated discrepancies between the care provided or resident status and what was documented in the MDS assessments.
Failure to Transcribe Physician's Orders and Complete Laboratory Tests
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards for one resident by not transcribing a physician's order for six blood tests into the electronic medical record and not ensuring the collection of the required blood specimens. The physician's order, dated 03/26/25, was present in the resident's medical record, but there was no documentation that the laboratory tests had been completed. During interviews, administrative staff confirmed that the order was not transcribed and the blood specimens were not collected as required.
Failure to Provide Scheduled Bathing Assistance and Maintain Documentation
Penalty
Summary
The facility failed to provide necessary assistance with bathing for a resident who was dependent on staff for activities of daily living due to weakness. A family member reported concerns about the resident's personal hygiene, specifically noting unclean fingernails and questioning whether scheduled weekly baths were being provided. Observations confirmed the presence of dark areas under the resident's fingernails on two consecutive days. Review of the resident's care plan indicated the need for staff assistance with bathing and transfers. Documentation for March, April, and May showed inconsistent records of completed or refused baths/showers, with several instances lacking any documentation of whether bathing was provided or refused. An administrative nurse confirmed the absence of required documentation for scheduled bathing assistance.
Missing Hospice Election Forms in Resident Records
Penalty
Summary
The facility failed to ensure that the medical records of two residents receiving hospice services contained the required hospice election forms. Review of the hospice contract and facility policy confirmed that providing and obtaining the hospice election form is a responsibility of both the hospice agency and designated facility staff. For one resident, a nurse's note documented enrollment in hospice for end-of-life care, but the corresponding hospice election of benefits form was missing from the medical record. For the second resident, both a physician's order for hospice admission and a nurse's note confirming hospice admission were present, yet the hospice election form was also absent from the record. An administrative nurse verified that both records lacked the necessary documentation.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from sexual and mental abuse, as evidenced by the actions of a staff member who took inappropriate images and videos of residents. This deficiency affected five current residents and one former resident, as identified through a review of a staff member's electronic device. The inappropriate actions were discovered when law enforcement notified the facility of the staff member's arrest, revealing the presence of these images and videos. The facility's policy on abuse, neglect, and exploitation, as well as its policy on employee social media use, were not effectively implemented or enforced. The policies clearly prohibit the taking and sharing of unauthorized photographs or recordings of residents, especially those that could demean or humiliate them. Despite these policies, a staff member engaged in such behavior, leading to the identification of multiple residents in the inappropriate content. The residents involved had varying levels of cognitive impairment, with some having intact cognition and others being moderately to severely impaired. The failure to protect these residents from abuse was identified as an Immediate Jeopardy situation, indicating a serious threat to their health and safety. The deficiency was considered past non-compliance as corrective actions were taken prior to the survey.
Removal Plan
- Terminated staff member (#2).
- Educated all staff on-duty and all on-coming staff on facility's policy/procedure for abuse, neglect and exploitation, and social media use.
- Completed assessments of all residents.
- Notified the medical director.
- Reviewed facility policies and resources and updated as necessary.
- Interviewed all staff to identify any allegation of misconduct to include taking of inappropriate photos/videos of residents.
- Maintained contact with law enforcement agencies to identify possible affected residents and appropriate next steps.
- Implemented behavior monitoring for all residents identified.
Failure to Protect Resident from Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to protect a resident from non-consensual sexual contact by another resident. The incident occurred when a staff member observed one resident with his hand down the front of another resident's pants. The resident who was subjected to the unwanted contact appeared distressed and attempted to swat the other resident away. The resident who initiated the contact was cognitively intact, while the resident who experienced the unwanted contact had severely impaired cognition due to dementia and Parkinson's disease. The incident was reported to the nursing staff, Executive Director, and social services, and local law enforcement was notified. The resident who experienced the unwanted contact was able to briefly describe the incident and reported not feeling in danger. The facility's policy on abuse, neglect, and exploitation, which prohibits non-consensual sexual contact, was not effectively implemented to prevent this incident.
Removal Plan
- Implemented 1 to 1 staff supervision/monitoring for Resident #1.
- Moved Resident #1's roommate to another room.
- Reeducated staff regarding 1 to 1 supervision and on the abuse, neglect, and exploitation policy.
- Interviewed other residents to determine if any other abuse occurred.
- Reported the concern to the North Dakota Department of Health and Human Services.
- Reported the concern to local Police Department.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of a pressure ulcer for a resident identified as having a stage IV pressure ulcer with exposed hardware. The facility did not evaluate risk factors that could impact the development of a pressure ulcer, nor did they implement, monitor, and modify interventions to reduce those risk factors. This resulted in the resident developing an avoidable, facility-acquired pressure ulcer. The resident was admitted to the facility following a fall and surgery for a broken right ankle. The facility's policy required regular skin assessments and documentation of any changes in wound status, appearance, color, wound healing, signs of infection, wound size, and stage. However, the staff failed to address the surgical incision on the resident's right ankle during daily dressing changes and did not document or report any changes in the wound status. The resident's progress notes indicated that the surgical wound was not properly assessed or monitored, leading to the development of a stage IV pressure ulcer with 80% hardware exposure. The facility did not identify the pressure ulcer before it progressed to this severe stage, and the staff failed to document wound measurements on the admission skin assessment and complete non-pressure weekly tracker assessments.
Removal Plan
- Assess the pressure ulcer to Resident #138 right ankle.
- Complete an investigation into the facility acquired pressure ulcer.
- Determine nursing staff failed to document wound measurements on the admission skin assessment.
- Determine nursing staff failed to complete non-pressure weekly tracker assessments.
- Determine nursing staff removed pressure relieving interventions from the care plan.
- Educate Resident #138 regarding the need for pressure relieving interventions.
- Update Resident #138's care plan.
- Audit other residents with surgical wounds and/or cam boots.
- Update other residents' care plans.
- Educate staff regarding skin injuries and interventions.
- Add surgical skin areas and wounds to the wound tracker (computer program).
- Complete audits on skin injuries.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four of the twelve sampled residents, which affected the accuracy of resident assessments and potentially the development of comprehensive care plans. For Resident #18, the facility did not correctly code the Preadmission Screening and Resident Review (PASRR) section, despite a PASRR Level II Outcome indicating a diagnosis of Bipolar II Disorder. This error was confirmed by a social services staff member during an interview. Additionally, the facility made errors in coding the medication sections for Residents #2 and #28. Resident #2's MDS was incorrectly coded to reflect seven days of insulin injections, although the resident was receiving Trulicity, a non-insulin medication, once a week. This mistake was acknowledged by an MDS coordinator. Similarly, Resident #28's MDS failed to indicate the use of a diuretic, despite physician orders for daily Chlorthalidone. This error was also confirmed by an MDS coordinator.
Failure to Follow Insulin Administration Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice for insulin preparation and administration for two residents. During an observation, a nurse prepared a NovoLog insulin pen for a resident and administered the insulin by inserting the needle into the resident's abdomen and pressing the injection button until the dose selector reached 0. However, the nurse did not keep the needle in the skin for up to 10 seconds as required by the facility's policy. In another instance, a different nurse prepared an Asepet insulin pen for another resident and primed the pen horizontally by dialing it to 2, which did not comply with the facility's policy for priming insulin pens. These actions resulted in a failure to follow the facility's insulin administration policy, potentially leading to inaccurate dosing.
Medication Labeling Deficiency During Insulin Administration
Penalty
Summary
The facility failed to ensure accurate labeling of medications during the administration of insulin for one resident. During an observation, a nurse prepared insulin for a resident and removed a plastic bag labeled with the resident's name from the medication cart. The bag contained NovoLog and Tresiba insulin pens. However, the NovoLog pen lacked a medication label with the resident's name and administration instructions, and the Tresiba insulin pen lacked an open date. This was contrary to the facility's policy on insulin administration, which requires documenting the open date on the pen body and verifying that the medication label matches the Medication Administration Record (MAR). An administrative nurse confirmed that staff are expected to follow the facility policy to ensure insulin pens have a label and an open date.
Failure to Notify Resident Representative and Physician
Penalty
Summary
The facility failed to notify the resident representative of a care conference for a resident who was reviewed for care conferences. The facility's policy requires that the comprehensive care plan be prepared by an interdisciplinary team, including the resident and the resident's representative, to the extent practicable. However, the medical record of the resident identified a representative as the primary power of attorney for medical and financial decisions, but there was no evidence that the facility notified this representative of the care conference. An administrative staff member confirmed the failure to notify the resident's representative. Additionally, the facility failed to notify a physician of a change in condition for a resident who experienced high blood sugar levels. The facility's policy mandates that when a resident presents with a possible change of condition, such as elevated blood glucose levels, the resident's physician should be notified. The medical record of the resident, who had a diagnosis of type 2 diabetes mellitus with hyperglycemia, showed multiple instances of blood sugar readings above the ordered parameters. Despite this, there was no evidence that the facility notified the resident's physician of these high readings. Interviews with administrative nurses confirmed that the facility staff failed to notify the physician of the high blood sugar readings. The lack of notification could prevent the physician from evaluating and prescribing an appropriate treatment plan. The resident's representative also stated that they had not been contacted regarding the resident's care plans or significant changes in the resident's status, further highlighting the communication deficiencies within the facility.
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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