Nelson County Health System Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcville, North Dakota.
- Location
- 108 E Nyhus Ave, Mcville, North Dakota 58254
- CMS Provider Number
- 355052
- Inspections on file
- 19
- Latest survey
- June 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Nelson County Health System Care Center during CMS and state inspections, most recent first.
A resident with a history of dementia, bipolar disorder, and physical aggression physically assaulted another resident on two occasions, including striking and pulling hair, after their wheelchairs became entangled in a common area. Despite existing care plans and hourly monitoring, staff did not prevent these incidents, resulting in physical abuse as defined by facility policy.
A resident with a long-term indwelling urinary catheter on enhanced barrier precautions did not receive care in accordance with infection control policies. A CNA failed to wear a gown during high-contact care, did not perform hand hygiene after glove removal, and improperly rinsed a contaminated collection container, despite facility policies requiring these actions. These lapses were observed during catheter care, resident transfer, and incontinence care.
A resident with dementia and severely impaired cognition exhibited repeated aggressive behaviors towards another resident, including kicking and verbal taunting. Despite having a behavior management plan, the facility failed to effectively control the resident's actions, resulting in multiple incidents of abuse and an unsafe environment. Staff interventions were insufficient, and attempts to transfer the aggressive resident to a more suitable care setting were unsuccessful.
A resident with Alzheimer's and dementia was administered morphine sulfate for anxiety and pain without prior attempts at non-pharmacological interventions or less restrictive medications. The facility lacked a pain management policy, and the resident's care plan did not address pain. Despite quarterly assessments indicating no pain, morphine was given multiple times without proper documentation or justification.
The facility did not submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) for two out of four reporting periods. The PBJ Long-Term Care Facility Policy Manual mandates quarterly submission of direct care staffing and census data. A review of the PBJ Data Staff Report CASPER Report confirmed the missing data for the specified quarters, as verified by an administrative staff member during an interview.
The facility did not review and revise comprehensive care plans for three residents, leading to discrepancies in care. One resident's care plan lacked an intervention for using a gluteal strap during transfers with a mechanical stand lift. Another resident's care plan was not updated to reflect the end of a walking program, causing inconsistencies with the care card used by CNAs. Additionally, a third resident's care plan did not address the use of antidepressant and anticoagulant medications, despite relevant physician's orders and diagnoses. These issues hindered staff's ability to provide appropriate care and ensure resident safety.
The facility did not consistently apply compression stockings for a resident with bilateral lower extremity edema, as per the physician's orders and care plan. Observations showed the resident wearing non-compression stockings or no stockings at all. Additionally, the facility failed to obtain a physician's order for a splint for another resident after hospital discharge, despite the resident's need for the splint due to swelling and pain. The order for the splint was discontinued without proper clarification or updating of the care plan.
The facility did not consistently use prescribed assistive devices and provide adequate supervision during transfers for two residents with mobility and cognitive impairments. For a resident with weakness and dementia, CNAs did not always use the gluteal and leg straps during mechanical stand lift transfers, despite care plan and physician's orders. Similarly, another resident requiring assistance with transfers and toilet use experienced inconsistent adherence to care plan instructions for one or two assists. CNAs made decisions based on the residents' behavior and condition on a given day, leading to potential safety risks.
The facility failed to provide appropriate toileting assistance for two residents, leading to extended periods without care and resulting in injuries and discomfort. Staff misunderstood the residents' needs and did not follow care plans, leaving residents at risk for skin breakdown and other complications.
The facility failed to ensure the safe and secure storage of medications in one medication cart. A nurse left the cart unattended for over eight minutes with six insulin pens/vials on top, and the cart was unlocked and out of view. Facility policy requires the cart to be locked when unattended and medications not to be left on top.
Staff compliance with standard infection control practices, specifically hand hygiene and glove use, was not ensured for several residents. A CNA did not perform hand hygiene before or after providing incontinence care, leading to potential cross-contamination risks. Another CNA failed to change gloves or perform hand hygiene while providing incontinence care, increasing the risk of infection transmission. Additionally, a CNA did not practice hand hygiene after using a stand lift to assist with toileting, touching various surfaces in the resident's room without proper hand hygiene.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with diagnoses including bipolar disorder, dementia, Parkinson's disease, and schizoaffective disorder exhibited physical aggression towards another resident. The care plan for this resident identified a history of wandering, refusing care, and both verbal and physical aggression, with interventions such as medication administration, positive approaches to care, and seeking additional staff assistance as needed. Despite these measures, the resident physically assaulted another resident on two occasions, first by striking her with a closed fist and then by slapping her and pulling her hair. Both incidents occurred in a common area when the residents' wheelchairs became entangled, and staff intervened to separate them without reported injury. The facility's policy prohibits all forms of abuse, including physical abuse such as hitting and slapping. Documentation showed that the aggressive resident was already on hourly checks due to elopement risk, and the other resident was also monitored hourly for safety following the incidents. The events were confirmed through medical record review, facility-reported incident documentation, and staff interviews, establishing that the facility failed to ensure residents remained free from abuse by not preventing the physical altercations.
Failure to Follow Infection Control Standards for Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for a resident with an indwelling urinary catheter who was on enhanced barrier precautions (EBP). During observation, a certified nurse aide (CNA) entered the resident's room, applied gloves but did not don a gown as required by EBP signage and facility policy. The CNA emptied the urine from the resident's leg bag into a collection container, disposed of the urine in the toilet, and rinsed the contaminated container under the sink faucet in a shared bathroom, contrary to policy which required use of a spray wand. The CNA then removed gloves but did not perform hand hygiene before obtaining equipment from the hallway and preparing for a resident transfer. During the transfer and subsequent incontinence care, the CNA again failed to change gloves between tasks and did not perform hand hygiene after glove removal. The CNA applied skin barrier cream and a clean brief, then handled the resident's nasal cannula and call light without washing hands. These actions were inconsistent with facility policies on hand hygiene, EBP, and catheter care, as confirmed by administrative staff during interview, who stated expectations for glove changes, hand hygiene, use of gowns, and proper cleaning of contaminated containers.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving a resident with severely impaired cognition who exhibited verbal and physical aggressive behaviors towards another resident. The aggressive resident, who has a history of dementia and cognitive decline, was documented to have repeatedly kicked and verbally taunted another resident, leading to multiple incidents of physical and psychosocial harm. Despite having a care plan in place that included interventions to manage the resident's behavior, such as anticipating needs, providing positive interactions, and diverting attention, these measures were insufficient in preventing the aggressive behavior. The incidents were documented over several days, with the aggressive resident repeatedly seeking out and antagonizing the same resident, resulting in physical altercations. Staff interventions included separating the residents and attempting to redirect the aggressive resident, but these efforts were not consistently effective. The facility's records show that the aggressive resident's behavior was escalating, with multiple documented instances of physical aggression and verbal taunting, despite staff attempts to manage the situation. The facility's failure to effectively implement and follow through with the behavior management plan resulted in an unsafe environment for the residents involved. The aggressive resident's behavior was not adequately controlled, leading to repeated incidents of abuse. The facility's inability to secure a transfer for the aggressive resident to a more suitable care environment further contributed to the ongoing risk of harm to other residents.
Failure to Ensure Resident is Free from Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, specifically morphine sulfate, which was administered without proper justification or documentation. The resident, who had diagnoses including Alzheimer's disease, obsessive-compulsive disorder, and dementia with agitation, was given morphine sulfate for anxiety and pain without prior attempts at non-pharmacological interventions or the use of less restrictive medications like acetaminophen. The resident's care plan did not address pain management, and quarterly pain assessments indicated no pain or non-verbal indicators of pain. Despite this, morphine was administered multiple times over a three-day period for anxiety and pain, often without a documented pain rating. The facility did not provide a policy on pain management or opioid use when requested, and the resident's medical record lacked documentation of pain assessments related to the new onset of pain. An administrative nurse confirmed the absence of pain documentation and the failure to use non-pharmacological interventions or less restrictive medications before administering morphine. The facility's actions did not allow the resident to attain or maintain their highest level of practicable well-being, as required by regulations.
Non-Compliance with PBJ Data Submission Requirements
Penalty
Summary
The facility failed to submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) for 2 out of 4 reporting periods. The Electronic Staffing Data Submission PBJ Long-Term Care Facility Policy Manual requires timely and accurate submission of direct care staffing and census data quarterly. Review of the PBJ Data Staff Report CASPER Report indicated that the facility did not submit data for the specified quarters, as confirmed by an administrative staff member during an interview.
Care Plan Review and Revision Deficiencies
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for three sampled residents, leading to deficiencies in care. For Resident #13, the care plan did not include an intervention to use the gluteal strap when transferring the resident with the mechanical stand lift, as observed during toileting and transfers. Resident #25's care plan was not updated to reflect the cessation of the walking program by Physical Therapy, resulting in a discrepancy between the care plan and the resident's current ambulation status noted on the care card used by CNAs. Additionally, Resident #32's care plan did not address the resident's use of antidepressant and anticoagulant medications, despite the presence of related physician's orders and diagnoses of atrial fibrillation and mood disorder. Observations during the survey highlighted instances where the care plans did not accurately reflect the residents' current needs and interventions required for their care. The lack of updated information in the care plans for Residents #13, #25, and #32 hindered the staff's ability to provide appropriate care, communicate effectively, and ensure resident safety. These deficiencies in care planning could potentially impact the quality of care provided to these residents and compromise their well-being.
Inconsistent Adherence to Compression Stocking and Splint Orders
Penalty
Summary
The facility failed to provide appropriate care and services for two sampled residents. For Resident #25, who had bilateral lower extremity edema, the facility did not consistently apply compression stockings as ordered for edema management, as noted in the physician's orders and care plan. Observations on multiple occasions showed the resident wearing non-compression stockings or no stockings at all, indicating a lack of adherence to the prescribed treatment plan. Staff acknowledged the expectation to apply compression stockings as ordered, highlighting a gap in implementation. Regarding Resident #26, who wore a splint to the left hand/wrist due to swelling and pain, the facility did not obtain a physician's order for the splint after the resident returned from the hospital. Despite the resident's reported need for the splint and instructions to wear it at all times, the order for the splint was discontinued on the treatment administration record without proper clarification or updating of the care plan. This failure to secure the necessary order and ensure compliance with the treatment plan raises concerns about the facility's oversight and communication regarding resident care.
Inconsistent Use of Assistive Devices and Supervision During Resident Transfers
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for two sampled residents (#13 and #19). For Resident #13, who had weakness and dementia, CNAs did not consistently use the gluteal strap and leg strap during transfers with a mechanical stand lift, leading to unsafe transfers. Despite the care plan and physician's order specifying the use of these assistive devices, CNAs did not consistently follow these guidelines, citing decisions based on the resident's behavior that day. Similarly, for Resident #19, who required assistance with transfers and toilet use, CNAs did not consistently follow the care plan's instructions for one or two assists, leading to potential risks during ambulation and transfers. The CNAs mentioned making decisions based on the resident's condition that day, indicating a lack of consistent adherence to established protocols.
Failure to Provide Appropriate Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting for two residents who required staff assistance. Resident #8, who has Alzheimer's disease and a history of falls, was supposed to receive supervision-limited assistance with toileting every 2-3 hours. However, the toileting log showed 43 instances where staff did not assist the resident as care planned, with gaps ranging from 3.5 to 14 hours. This lack of assistance led to an incident where the resident fell and sustained injuries, including a broken hand, which required medical attention and an orthopedic consult. Interviews with CNAs revealed a misunderstanding of the resident's need for assistance, as they believed the resident was independent in toileting. Resident #13, who has dementia and is at risk for skin breakdown and falls, required assistance with a mechanical stand lift for toileting every 2-3 hours. The toileting log showed 82 instances where staff failed to assist the resident as care planned, with gaps ranging from 3.5 to 13 hours. Observations revealed that the resident was left in a very wet incontinent product for five hours, causing discomfort and agitation. CNAs attempted to assist the resident but did not follow through when the resident exhibited distress, and they failed to inform the licensed nurse about the resident's inability to use the mechanical lift and the lack of toileting. The facility did not provide a policy related to the toileting of residents, which contributed to the deficiencies observed. The lack of adherence to care plans and failure to provide timely assistance with toileting placed the residents at risk for skin breakdown, poor hygiene, and other complications. Interviews with staff and record reviews confirmed the lapses in care, highlighting the need for better communication and adherence to care plans to ensure resident safety and dignity.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications in one medication cart. During an observation, a staff nurse left the medication cart unattended for over eight minutes with six insulin pens/vials on top of the cart. The cart remained unlocked in the hallway and out of the nurse's view. The facility's policy, revised in 2016, requires that the medication cart be locked when unattended and that medications should not be left on top of the cart. An administrative nurse confirmed that staff are expected to secure medications within the cart and lock it when out of eyesight.
Infection Control Practices: Hand Hygiene and Glove Use Deficiencies
Penalty
Summary
The facility failed to ensure staff compliance with standard infection control practices, specifically related to hand hygiene and glove use, for several residents as observed during the survey. In one instance, a certified nurse aide (CNA) did not perform hand hygiene before or after providing incontinence care to Resident #16, leading to potential cross-contamination risks. Another CNA failed to change gloves or perform hand hygiene while providing incontinence care to Resident #1, further increasing the risk of infection transmission. Additionally, a CNA did not practice hand hygiene after using a stand lift to assist Resident #6 with toileting, touching various surfaces in the resident's room without proper hand hygiene.
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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