Sanford Hillsboro Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsboro, North Dakota.
- Location
- 12 3rd St Se, Hillsboro, North Dakota 58045
- CMS Provider Number
- 355061
- Inspections on file
- 15
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Sanford Hillsboro Care Center during CMS and state inspections, most recent first.
A resident receiving Lasix and Tramadol did not have their care plan updated to identify problems or interventions related to these medications. Facility policy requires care plans to be modified to reflect current care needs, but this was not done, as confirmed by administrative staff.
A medication aide prepared medications for a resident and later handed them to a nurse, who then administered them, contrary to facility policy and professional standards requiring staff to administer only medications they have personally prepared. The resident's medication administration record reflected the aide as the person who administered the medications, despite the nurse actually giving them.
A resident with a history of frequent falls and weakness experienced a fall during a transfer from a tub chair to a wheelchair when staff failed to lock the tub chair brakes as required by facility policy. The tub chair rolled back, causing the resident to fall, as confirmed by interviews and documentation.
A resident suffered burns from hot coffee due to the facility's failure to monitor beverage temperatures, with machines dispensing liquids at up to 181°F. Despite instructions to cool beverages, staff did not routinely check temperatures, leading to an Immediate Jeopardy situation. Additionally, the resident experienced an unsafe transfer with a mechanical lift, highlighting inadequate assistance and improper use of assistive devices.
A facility failed to accurately communicate a resident's code status, leading to a potential misinterpretation of their advance directives. The resident's medical record indicated a preference for chest compressions but no intubation, yet a red dot on their chart suggested a DNR status. An administrative nurse confirmed this discrepancy, which could mislead staff during a medical emergency.
A facility failed to provide a written notice of transfer to a resident or their representative, as required by their policy. The deficiency was identified during a review of the facility's 'Transfer to Hospital Guide,' which mandates timely notification and documentation in the medical record. A review of a resident's medical record revealed a lack of documentation for a hospital transfer, and an administrative staff member confirmed the failure to provide the necessary written notice.
A nurse failed to prime a Humalog insulin pen before administering it to a resident, contrary to the facility's policy. The policy requires priming by turning the dosage knob to '2' units and ensuring a drop of insulin appears. An administrative staff member confirmed the expectation for staff to follow this procedure.
The facility failed to follow infection control standards during care for three residents, involving improper hand hygiene and glove use. A CNA and a nurse did not perform hand hygiene after removing gloves during perineal care, dressing changes, and insulin administration, potentially spreading infections. An administrative nurse confirmed the expectation for staff to adhere to infection control guidelines.
The facility did not post daily staffing data for nine out of fifteen days, affecting six day shifts, six evening shifts, and one night shift. This omission was confirmed by an administrative staff member, hindering transparency about staffing levels for residents and visitors.
Failure to Update Care Plan for Resident Receiving Diuretic and Opioid
Penalty
Summary
The facility failed to review and revise the care plan to reflect the current status for one resident who was receiving unnecessary medications. Record review showed that the resident had physician's orders for Lasix, a diuretic, and Tramadol, an opioid pain medication, both administered twice daily. However, the resident's care plan did not identify problems or interventions related to the use of these medications. This omission was confirmed by an administrative staff member, who acknowledged that the care plan had not been updated as required by facility policy, which states that the plan of care should be modified to reflect the care currently required or provided for the resident.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
A medication aide prepared a cup of medications and applesauce for a resident and placed them in the medication cart drawer. Later, the aide handed these prepared medications to a nurse, who confirmed the resident's name and then administered the medications to the resident. The aide acknowledged that she had prepared the medications earlier that morning and had attempted to administer them twice before handing them to the nurse. The facility's policy and professional nursing standards both require that staff only administer medications they have personally prepared, and not those prepared by another individual. Review of the resident's electronic medication administration record showed that the medications were documented as administered by the medication aide, despite the nurse actually giving them. An administrative staff member confirmed that the facility's expectation is for medication aides and nurses to administer only those medications they have personally prepared. This sequence of actions did not follow the facility's policy or professional standards for medication administration.
Failure to Lock Tub Chair Brakes During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to properly utilize assistive devices necessary to prevent accidents for a resident with a history of frequent falls and an ADL deficit related to weakness. The facility's policies required staff to lock brakes on wheelchairs and tub chairs during transfers, and to ensure safe and proper use of assistive devices. However, during a transfer from a tub chair to a wheelchair in the shower room, the brakes on the tub chair were not locked. As a result, the tub chair rolled back while the resident was being assisted to stand, causing the resident to fall onto his right side. The incident was confirmed through resident and staff interviews, as well as a review of the medical record and facility policies. The event review documented that the CNA did not lock the tub chair brakes, directly leading to the fall.
Failure to Prevent Burn Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, resulting in a burn injury to a resident. During the on-site recertification survey, it was observed that the coffee and hot water machines dispensed liquids at dangerously high temperatures, reaching up to 181 degrees Fahrenheit. Despite posted instructions to add ice or wait three minutes before serving, staff did not routinely monitor or adjust the temperatures, leading to a resident spilling hot coffee and sustaining burns on her thighs and labia. The resident involved in the incident had a history of falling and was diagnosed with dementia. On the day of the incident, she was sitting in the dining room when she spilled hot coffee onto her lap. Immediate first aid was administered, and the resident was treated for first and second-degree burns. The survey team identified an Immediate Jeopardy situation due to the lack of temperature monitoring and the potential risk of serious burns to all residents. Additionally, the facility failed to provide adequate assistance during a mechanical lift transfer for the same resident. The resident, who required assistance due to her medical condition, was observed having difficulty holding onto the lift handles, resulting in an improper transfer. The harness sling slid up her back, causing her elbows to bow outward, indicating improper use of the assistive device. This placed the resident at risk for accidents and injury during transfers.
Removal Plan
- Disconnected power to coffee machines, coffee and hot water with temperatures at or below 150 degrees were made available in carafes
- Implement focus audit to monitor coffee and hot water temperatures in carafes
- Education was provided to dietary and nursing staff
- Message sent to nursing staff to review the policy related to hot liquids
Inaccurate Communication of Resident's Code Status
Penalty
Summary
The facility failed to ensure that all forms of communication accurately reflected a resident's code level status, which is crucial for honoring the resident's advance directives. Specifically, for one resident, the medical record indicated a preference for Code Level 1, which included chest compressions but no intubation. However, a red dot on the resident's chart, which staff interpreted as a do not resuscitate (DNR) order, contradicted this directive. An administrative nurse confirmed that the red dot would lead staff to mistakenly identify the resident as DNR, highlighting a discrepancy between the resident's documented wishes and the facility's communication system. This inconsistency limited the facility's ability to convey the resident's choices accurately in a medical emergency.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their representative, as required by their policy. This deficiency was identified during a review of the facility's policy titled 'Transfer to Hospital Guide,' which mandates timely notification to the resident, family member, or legal representative, with documentation in the medical record. The review of the medical record for a resident who was transferred to the hospital revealed a lack of documentation indicating that a written transfer notice was provided. An administrative staff member confirmed the failure to provide the necessary written notice during an interview.
Failure to Prime Insulin Pen as per Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of insulin for a resident. During an observation, a nurse prepared a Humalog insulin pen for a resident without priming it as required by the facility's policy. The policy, revised in December 2023, mandates that the insulin pen should be primed by turning the dosage knob to '2' units and pressing the button until a drop of insulin appears. However, the nurse directly dialed the pen to the prescribed units without priming it, which could lead to an inaccurate dose being administered. An administrative staff member confirmed that it is expected for staff to prime insulin pens according to the policy. This oversight was identified during a review of the facility's policy on insulin administration and through direct observation of the nurse's actions.
Infection Control Breach in Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to adhere to infection control standards during the care of three residents, specifically in the areas of hand hygiene and glove use. A certified nurse aide assisted a resident with perineal care and other tasks without performing hand hygiene after removing gloves, which is a breach of the facility's hand hygiene policy. Similarly, a nurse conducted perineal care, dressing changes, and applied ointment to another resident without changing gloves or performing hand hygiene between tasks, further violating infection control protocols. Additionally, the same nurse failed to remove gloves and perform hand hygiene after scanning a resident's blood glucose levels and before administering insulin. The nurse continued to use the same gloves while handling equipment and typing on a computer, which could potentially spread infections. These actions were observed and documented, and an administrative nurse confirmed that staff are expected to follow infection control guidelines, indicating a lapse in adherence to established procedures.
Failure to Post Daily Staffing Data
Penalty
Summary
The facility failed to post daily staffing data for all shifts on nine out of fifteen days reviewed, specifically from May 14 to May 28, 2024. This deficiency was identified through a review of daily staffing information and confirmed during an interview with an administrative staff member. The missing data included the number of staff working on six day shifts, six evening shifts, and one night shift, which prevented residents and visitors from being informed about the staffing levels for each shift.
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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