Parkside Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Lisbon, North Dakota.
- Location
- 501 3rd Ave W, Lisbon, North Dakota 58054
- CMS Provider Number
- 355116
- Inspections on file
- 15
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Parkside Lutheran Home during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices, such as feeding tubes and urinary catheters, and did not make PPE readily available. Additionally, staff did not consistently follow catheter care and hand hygiene protocols, as observed with a resident's urinary drainage bag being placed on the floor and CNAs not sanitizing hands after providing care. These actions violated the facility's infection control policies.
The facility failed to ensure call lights were within reach for a resident with Alzheimer's and mobility issues, risking falls and injury. A resident expressed concerns about staff interactions, and an observation confirmed the call light was out of reach while the resident needed assistance. An administrative nurse acknowledged the expectation for staff to keep call lights accessible.
A facility failed to provide a written notice of transfer to a resident or their representative when the resident was transferred to a hospital. The medical record lacked documentation of the notice, and an administrative staff member confirmed that providing such notice is expected when a resident is hospitalized.
A facility failed to provide a written bed hold notice to a resident or their representative during a hospital transfer. The deficiency was identified through a review of medical records and staff interviews, revealing a lack of documentation for the notice. An administrative staff member confirmed the expectation for staff to issue a bed hold notice whenever a resident is out overnight.
The facility failed to update care plans for three residents to reflect their current medication use, including a diuretic, an anticoagulant, and an antidepressant, as identified through record reviews and staff interviews.
A facility failed to follow professional standards by not transcribing a physician's order for a resident's foley catheter after the resident returned from the hospital. The omission was confirmed by an administrative nurse, who acknowledged that the order was missed during transcription.
The facility failed to properly use gait belts during stand-pivot transfers, as observed with two residents requiring assistance. One resident, with Alzheimer's and a history of femur fracture, was assisted by a CNA who pulled upward on her pants instead of using the gait belt correctly. Another resident, with severe vascular dementia and mobility issues, was similarly assisted by two CNAs. The facility's policy mandates the use of gait belts for safe transfers.
A facility failed to assess a resident with PTSD and identify known triggers, which are essential for trauma-informed care. The resident's medical record lacked an assessment of past traumas, and the care plan did not include known triggers or interventions to prevent re-traumatization. An administrative nurse confirmed the staff's failure to assess and implement necessary interventions. Additionally, the facility could not provide a policy addressing PTSD.
A facility failed to conduct the required Abnormal Involuntary Movement Scale (AIMS) screenings for a resident receiving the antipsychotic medication Abilify, as per their policy. The policy requires AIMS screenings every six months to monitor for tardive dyskinesia, but the resident's medical record lacked the necessary reassessments. An administrative nurse confirmed the expectation for biannual reassessments, highlighting a lapse in adherence to the facility's guidelines.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for several residents, particularly in the application of Enhanced Barrier Precautions (EBP). Resident #11, who had multiple wounds requiring dressing changes, was not placed on EBP, and personal protective equipment (PPE) was not made readily available to staff. Similarly, Resident #90, with a feeding tube, and Resident #139, with a urinary catheter, were not placed on EBP, and PPE was not accessible, despite the facility's policy requiring such measures for residents with indwelling medical devices. In addition to the lack of EBP, the facility's staff did not consistently follow proper catheter care and hand hygiene protocols. Observations revealed that CNAs handling Resident #139's urinary drainage bag failed to keep it off the floor and did not perform hand hygiene after handling soiled equipment. The CNA also reconnected the drainage tube without sanitizing it after it had been dropped on the floor. These actions were contrary to the facility's policies on catheter care and hand hygiene. Further deficiencies were noted in hand hygiene practices during resident care. CNAs assisting Residents #14 and #25 with toileting and peri-care did not perform hand hygiene after removing gloves and before proceeding with other tasks. This failure to sanitize hands after providing care and before exiting the room or performing additional tasks was a direct violation of the facility's hand hygiene policy, which emphasizes hand hygiene as a primary means of preventing infection transmission.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure care and services were provided according to accepted standards of quality for a resident observed during stand-pivot transfers. Specifically, the staff did not place call lights within the resident's reach, which placed residents at risk for falls and/or injury. During interviews, a resident expressed concerns about the staff's interaction with her roommate, who frequently asked to go to the bathroom but often found the call light out of reach. An observation confirmed that the resident was sitting in her wheelchair with the call light attached to the bed, out of reach, while she expressed a need to use the bathroom. The resident's medical record indicated diagnoses of Alzheimer's disease, dementia, osteoarthritis, and a history of left femur fracture, with a care plan requiring assistance for locomotion and transfers. An administrative nurse confirmed the expectation that staff should ensure call lights are within reach of residents.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their representative, which is a requirement when a resident is transferred to a hospital. This deficiency was identified during a review of the medical records for a resident who was transferred to a hospital. The medical record did not contain documentation that the facility had provided the necessary written notice of transfer. An administrative staff member confirmed during an interview that it is expected for staff to provide such notice whenever a resident is hospitalized.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed hold to a resident or their representative during a hospital transfer. This deficiency was identified during a review of the medical records and staff interviews. Specifically, the medical record of a resident who was transferred to a hospital lacked documentation that a written bed hold notice was provided. An administrative staff member confirmed that it is expected for staff to provide such a notice whenever a resident is out of the facility overnight.
Failure to Update Care Plans for Medication Use
Penalty
Summary
The facility failed to review and revise the comprehensive care plans to reflect the current status for three residents. Resident #5's care plan did not address the use of a diuretic medication, despite the quarterly Minimum Data Set (MDS) and current physician's orders indicating that the resident received Lasix daily. Similarly, Resident #7's care plan failed to include the use of an anticoagulant medication, even though the MDS and physician's orders showed that the resident was on Eliquis daily. Additionally, Resident #30's care plan did not reflect the use of an antidepressant medication, despite the MDS and physician's orders indicating daily administration of Mirtazapine. These omissions in the care plans were identified through observation, record review, and staff interviews, highlighting a failure in the facility's process to ensure that care plans are updated to communicate residents' current medication needs effectively.
Failure to Transcribe Physician's Order for Catheter
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding physician's orders for a resident with a catheter. During the survey, it was observed that the resident had a catheter bag under her wheelchair. Upon reviewing the resident's medical record, it was found that after returning from the hospital, the current physician's orders did not include an order for the resident's foley catheter. An administrative nurse confirmed that the staff failed to enter the order for the catheter, indicating that the order was missed during transcription when the resident returned from the hospital.
Failure to Properly Utilize Gait Belts During Transfers
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury during stand-pivot transfers for one of the sampled residents. Observations revealed that a certified nurse aide (CNA) placed a gait belt around a resident's waist, tightened it, locked the brakes on the wheelchair, and assisted the resident to stand by pulling upward on the back of her pants. This action was contrary to the facility's policy, which mandates the use of a gait belt for all residents requiring assistance with transfers and ambulation to ensure safety from injury. The resident involved had a medical history that included Alzheimer's disease, dementia, osteoarthritis, and a history of left femur fracture, and required assistance with transfers as identified in her care plan. Another observation showed two CNAs assisting another resident with toileting, where one CNA placed a gait belt around the resident's waist and assisted her to stand by pulling upward on the back of her pants. This resident had diagnoses including abnormalities of gait/mobility, disorders of bone density/structure, right hemiplegia following a cerebral infarction, and severe vascular dementia, and also required assistance with transfers. An administrative nurse confirmed that staff were expected to utilize a gait belt when transferring residents.
Failure to Assess PTSD and Identify Triggers
Penalty
Summary
The facility failed to assess a resident with a history of Post-Traumatic Stress Disorder (PTSD) and identify known triggers, which is crucial for providing trauma-informed care. The medical record of the resident, who has a complex psychiatric history including PTSD, lacked an assessment addressing past traumas. Additionally, the care plan did not identify known triggers or list interventions to prevent re-traumatization. An administrative nurse confirmed that staff did not assess residents with PTSD, identify their known triggers, or implement interventions to prevent re-traumatization. Furthermore, the facility was unable to provide a policy addressing PTSD.
Failure to Conduct Required AIMS Screenings for Antipsychotic Medication
Penalty
Summary
The facility failed to manage and monitor a resident's drug regimen effectively, which is necessary to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility did not complete the required Abnormal Involuntary Movement Scale (AIMS) screenings for a resident receiving the antipsychotic medication Abilify, which is used to treat major depression and psychosis. The facility's policy mandates that AIMS screenings be conducted every six months for residents on neuroleptic medications to assess for tardive dyskinesia, an involuntary movement disorder. However, the medical record for the resident in question did not include the necessary reassessments for January 2024 and July 2024. During the survey, it was confirmed by an administrative nurse that the expectation was for staff to reassess any resident receiving antipsychotic medication every six months. Despite this policy, the facility failed to adhere to its own guidelines, as evidenced by the absence of the required AIMS screenings in the resident's medical record. This oversight could potentially lead to adverse reactions to the medication, such as tardive dyskinesia, although the report does not specify any such outcomes for the resident involved.
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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