Souris Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Velva, North Dakota.
- Location
- 300 Main St S, Velva, North Dakota 58790
- CMS Provider Number
- 355109
- Inspections on file
- 20
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Souris Valley Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, dementia, and a history of repeated falls reported a fall with head impact and a new “knot” on the back of the head, which was confirmed on assessment with bruising. Facility policy required that in cases of suspected head injury, the physician be notified by phone rather than by fax. Instead, staff sent a fax to the physician and later used email to communicate that neuro checks and VS were stable and to report multiple recent falls. An administrative staff member confirmed that the physician was not notified by phone about the head injury, resulting in a deficiency for failure to follow the facility’s fall management and physician notification policy.
A resident’s care plan was not updated to reflect improved physical mobility and ADL status, despite facility policy requiring quarterly review and revision with significant changes in condition. The care plan continued to document a need for one- and two-person assistance with bed mobility, positioning, turning, oral care, dressing, and transfers, while the resident’s MDS showed no upper or lower extremity impairment and independence with oral hygiene, dressing, bed mobility, sit-to-stand, toilet transfers, and wheelchair mobility. An administrative staff member confirmed that staff failed to revise the care plan to match the resident’s current functional ability, limiting staff communication of needs and continuity of care.
Staff did not use required safety straps on bath chairs for two residents needing assistance during bathing, resulting in a fall and hip fracture for one resident and leaving another unsecured in a whirlpool tub. The facility's policy required safety belts to be used at all times, but staff failed to follow this protocol and did not perform a nursing assessment after the fall.
A resident sustained a left hip fracture after falling from a bath chair when not secured with a safety strap during bathing. CNAs transferred the resident from the floor using a mechanical lift without prior nursing assessment, and the facility's investigation omitted key details from staff interviews regarding the incident and staff actions.
Staff did not follow established protocols after a resident with dementia and mobility deficits fell from a bath chair and sustained a hip fracture. CNAs moved the resident using a mechanical lift before a nurse performed a full-body assessment, and later used a sit-to-stand lift not included in the care plan. The nurse's assessment was limited to a skin check and basic observation, failing to meet policy requirements for post-fall evaluation.
A transcription error in a LTC facility led to a resident receiving long-acting insulin in the morning instead of the evening as prescribed. This resulted in elevated blood sugar levels and subsequent hospitalization for diabetic ketoacidosis, dehydration, and hyperglycemia. An administrative nurse confirmed the error in insulin administration.
The facility failed to provide appropriate supervision and use assistive devices for a resident with severely impaired cognition and a history of falls. Staff did not follow the care plan, leading to the resident attempting self-transfers and experiencing multiple falls, including one that resulted in a head laceration and skin tears.
A resident experienced unresolved pain and anxiety due to the facility's failure to administer PRN pain and anxiety medications as ordered. Despite physician orders and the resident's frequent pain, staff did not provide the medications as needed and failed to inform the physician about the increased use of PRN pain medication.
The facility failed to ensure accurate MDS coding for four residents, impacting their assessments and care plans. Errors included incorrect discharge status, unreported significant weight loss, misidentified pressure ulcers, and incorrect medication coding.
The facility failed to update the comprehensive care plans for five residents, resulting in outdated information regarding their medical conditions, medications, and care needs. This deficiency was confirmed through record reviews, facility policy reviews, and staff interviews.
The facility failed to maintain the dignity of two residents who required assistance with dressing. Both residents were observed wearing soiled clothing on multiple occasions, contrary to the facility's policy on resident dignity. An administrative nurse confirmed that staff are expected to change soiled clothing and ensure residents are fully dressed after care.
The facility failed to notify a resident's physician of significant weight loss, as required by policy. The resident, diagnosed with dementia and diabetes, experienced a 9.9% weight loss over 90 days, but the medical record lacked documentation of provider notification. An administrative nurse confirmed this oversight.
The facility failed to ensure staff followed standards of practice for administering intermediate-acting insulin. A nurse administered 18 units of Humalog Mix 75/25 insulin to a resident at 5:19 p.m., but the resident did not receive their supper meal until 5:44 p.m., 25 minutes later. The prescribing information requires it to be injected within 15 minutes before a meal. An administrative nurse confirmed that staff are expected to administer intermediate insulin within this timeframe.
The facility failed to ensure staff provided care and services for a resident with a CAM Boot and orders to keep the right foot elevated. Observations showed multiple instances where the resident's foot was not elevated, and documentation did not indicate who was responsible for the CAM Boot or foot elevation. An administrative staff member confirmed that nursing staff were expected to determine responsibility and document it, but this was not done.
The facility failed to maintain acceptable nutritional status for a resident who experienced a 27% weight loss over three weeks. Staff did not perform weekly weights as required, failed to re-weigh the resident, and did not document or address the significant weight loss.
The facility failed to limit the use of a PRN psychotropic medication, Lorazepam, to 14 days as required by their policy. The physician's order did not include a rationale for its extended use or a stop date. This oversight was confirmed by an administrative nurse during an interview.
The facility failed to follow infection control standards for three residents under enhanced barrier precautions (EBP). Staff did not adhere to policies on hand hygiene, glove use, and PPE, leading to improper handling of linens and resident care activities. These actions were confirmed during interviews with administrative nurses.
The facility failed to assess a resident's pneumococcal status and provide education on the benefits and potential side effects of the vaccination, as required by their policy. This deficiency was confirmed through record review and staff interviews.
Failure to Notify Physician by Phone After Resident Head Injury
Penalty
Summary
The facility failed to promptly notify a resident’s physician by phone of a head injury following a fall, as required by its own fall prevention and management policy. The policy, revised 10/14/25, stated that for residents with suspected head injury, physicians should be notified by phone and not fax. The resident involved had diagnoses including Alzheimer’s disease, dementia, and repeated falls, and a care plan identifying falls and gait/balance problems. On 12/06/25 at 6:40 a.m., progress notes documented that the resident came to the nursing station stating she had fallen in her room, hit her head, and had “another knot” on the back of her head; assessment found a knot with bruising to the right back of the head, and staff sent a fax to the physician. Later that day at 2:07 p.m., documentation showed the physician was notified by email with information that neurological checks and vital signs were stable, and on 12/09/25, the physician was informed the resident had eight falls since 10/07/25, six of them since 11/20/25. During interview, an administrative staff member confirmed the facility did not notify the physician by phone regarding the 12/06/25 head injury, contrary to facility policy. This sequence of events, including the resident’s documented fall history, the identified head injury with bruising, and the use of fax and email instead of a phone call, formed the basis for the deficiency related to failure to notify the physician as required.
Failure to Update Care Plan to Reflect Improved ADL and Mobility Status
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect the resident’s current functional status, as required by facility policy and federal regulations. The facility’s care plan policy, dated December 1, 2025, required each resident to have an individualized, person-centered, comprehensive plan of care with measurable goals and timetables, and directed that the interdisciplinary team review care plans at least quarterly and update them with any significant change in condition. Record review showed that one resident’s care plan, last revised on November 1, 2024, continued to document a need for assistance of one staff member for bed mobility, positioning, turning, oral care, dressing, and transfers between surfaces, and assistance of two staff members for moving between lying and sitting positions. However, the resident’s MDS assessment identified that the resident had no impairment of upper or lower extremities and was independent with oral hygiene, upper and lower body dressing, bed mobility, sit-to-stand, toilet transfers, and wheelchair mobility. The facility did not update the care plan to reflect this improvement in physical mobility and ADL status, and an administrative staff member confirmed that staff failed to revise the care plan to match the resident’s current functional ability. This failure limited staff’s ability to communicate needs and ensure continuity of care.
Failure to Use Bath Chair Safety Straps and Provide Adequate Supervision During Bathing
Penalty
Summary
Staff failed to provide appropriate supervision and use of assistive devices for two residents who required assistance during bathing. Specifically, staff did not utilize the bath chair safety strap as required by facility policy, which states that safety belts must be used for bathing units and lifts to reduce the risk of injury. One resident, who had impaired balance, limited mobility, and required staff assistance for bathing and transfers, was not secured with the safety strap during a bath. As a result, the resident fell from the bath chair and sustained a left femoral neck (hip) fracture. The incident was confirmed through staff interviews, medical record review, and facility-reported incident documentation. Another resident, who was dependent on staff for bathing and required substantial assistance with transfers, was observed seated in a whirlpool tub with the safety strap not secured. The staff member present stated that the strap had been removed because the resident was sliding down in the chair and admitted to forgetting to reapply it. These actions were in direct violation of the facility's bathing policy and the expectation that the safety belt should always be secured when residents are in the bath chair. Additionally, after the fall, staff failed to perform a nursing assessment prior to moving or assisting the resident off the floor. Interviews with staff revealed inconsistencies in the use of the safety belt and the process followed after the fall. The lack of adherence to safety protocols and failure to assess the resident post-fall contributed to the deficiency identified by surveyors.
Failure to Investigate and Document Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate and document an alleged violation of neglect involving a resident who fell from a bath chair and sustained a left femoral neck (hip) fracture. The incident occurred when the resident was not secured in the bath chair with the safety strap during bathing. The certified nurse aide (CNA) responsible for the resident admitted to not using the safety strap, and the resident fell after reaching for the door on the tub. Following the fall, the CNAs used a mechanical lift to transfer the resident from the floor back to the bath chair without a nurse's assessment, and then later transferred the resident to her wheelchair using a sit-to-stand lift. Staff interviews revealed inconsistencies and omissions in the facility's investigation. The CNAs involved described the sequence of events, including the lack of use of the safety strap and the delay in obtaining additional help. The nurse who later entered the room was informed of the fall only after noticing a lift sheet under the resident and questioning the situation. Nursing progress notes documented the fall, the resident's subsequent pain, and the eventual transfer to the hospital for evaluation and treatment of the hip fracture. The facility's internal investigation did not include all relevant details discovered during staff interviews, such as the failure to secure the resident in the bath chair and the improper transfer of the resident post-fall without prior nursing assessment. The investigation summary concluded there was no willful intent to neglect, attributing the fall to the resident's spontaneous movement, but failed to address the staff actions and omissions that contributed to the incident.
Failure to Follow Post-Fall Assessment and Safe Transfer Protocols
Penalty
Summary
Staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall from a bath chair. The facility's policy required that after a fall, the resident should not be moved and a licensed nurse must perform a full-body assessment to determine injury before any transfer. However, after the resident fell from the bath chair and sustained a left femoral neck (hip) fracture, certified nurse aides (CNAs) moved the resident from the floor back to the bath chair using a mechanical lift without waiting for a nurse to assess the resident. The CNAs reported waiting for help for 10-15 minutes before transferring the resident themselves, and only after the transfer did a nurse arrive to perform a skin check and basic assessment. The resident involved had a history of dementia, impaired balance, limited mobility, and weakness, and required assistance of two with a gait belt for transfers. The care plan did not include the use of a sit-to-stand lift, which was used by staff following the incident. The nurse did not perform a full-body assessment prior to the transfer, as required by policy, and the transfer method used was not part of the resident's care plan or assessed for safety. These actions and inactions resulted in a failure to follow established protocols for post-fall assessment and safe transfer, potentially contributing to further injury and pain for the resident.
Insulin Administration Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors, specifically in the administration of insulin. A transcription error occurred during the admission process, resulting in the long-acting insulin dose being scheduled for 8 AM instead of the prescribed 8 PM. This error led to the resident not receiving the necessary insulin at the correct time, which may have contributed to the resident's hospitalization. The resident's medical record indicated that the physician's order was for 7 units of long-acting insulin to be administered every evening. However, the medication administration record showed that the insulin was given in the morning. As a result, the resident experienced elevated blood sugar levels, a low-grade fever, and vomiting, leading to a hospital visit where they were diagnosed with diabetic ketoacidosis, dehydration, and hyperglycemia. An administrative nurse confirmed the failure to administer the insulin as ordered.
Failure to Provide Adequate Supervision and Use Assistive Devices
Penalty
Summary
The facility failed to provide appropriate and sufficient supervision and assistive devices for a resident who required staff assistance and a gait belt during transfers. This deficiency was identified during a standard survey when it was observed that staff did not follow the care plan for a resident with severely impaired cognition and a history of falls. The resident was at risk for falls due to balance difficulty, weakness, and unsteadiness, and required extensive assistance of two staff members with transfers using a gait belt. However, staff were observed not using the gait belt appropriately and not providing the required level of assistance during transfers and toileting, leading to the resident attempting self-transfers and experiencing falls, including one that resulted in a head laceration and skin tears requiring emergency room treatment and sutures. The resident had multiple falls within a short period, indicating a failure to implement and follow the care plan effectively. Observations showed that staff either did not use the gait belt or did not provide the necessary assistance during transfers, which directly contributed to the resident's falls and injuries. Interviews with facility staff confirmed that the care plan was not followed as expected, leading to the identified deficiency.
Removal Plan
- Inservice and education on appropriate actions/interventions per care plan specific to toileting and transfers to meet residents needs and prevent injury with the staff member directly involved in the deficient practice, all nursing staff on duty, and on-coming staff.
- Review of Resident's transfer requirements as outlined in their individual care plans.
- Review of facility policies and resources for questions/concerns.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #31, who experienced frequent and severe pain. Despite having physician orders for Acetaminophen, Tramadol, and Lorazepam, the resident did not receive these medications as needed. On multiple occasions, the resident's requests for pain and anxiety medications were denied or delayed, causing significant distress and anxiety. For instance, on one day, the resident did not receive any PRN doses of Tramadol or Lorazepam, and on another day, the resident received only two doses of Tramadol despite requesting it three times. The facility's records and interviews revealed that the staff did not follow the physician's orders or the facility's pain management policy. The resident's medical records indicated frequent pain rated at 10 on a 0-10 scale, affecting sleep and daily activities. Despite this, the staff failed to administer the medications as prescribed and did not inform the physician about the increased use of PRN pain medication, as suggested by the pharmacy reviews. The resident's care plan aimed to prevent interruptions in normal activities due to pain, but this goal was not met. Interviews with the resident and staff confirmed the issues with medication administration. The resident expressed anxiety and distress over not receiving the medications, and an administrative nurse acknowledged that the medications could have been given as requested. The facility's failure to administer PRN pain and anxiety medications as ordered and to communicate effectively with the physician contributed to the resident's unresolved pain and anxiety.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four residents, which impacted the accuracy of their assessments and potentially the development of their comprehensive care plans. For Resident #44, the discharge status was incorrectly coded as a discharge to a short-term general hospital instead of an assisted living facility, despite clear documentation in the medical record and physician's orders indicating the correct discharge location. This error was confirmed by a staff member during an interview. Resident #35 experienced a significant weight loss of 25% over 180 days, but this was not accurately reflected in the quarterly MDS. The dietary manager confirmed the incorrect coding during an interview. Accurate weight tracking is crucial for monitoring the resident's nutritional status and ensuring appropriate interventions. Resident #20 had two stage two pressure ulcers present on admission, but the quarterly MDS incorrectly indicated that these ulcers were not present on admission. This discrepancy was confirmed by an administrative nurse. Additionally, Resident #29's MDS failed to correctly identify the use of an antiplatelet medication, clopidogrel, and instead incorrectly identified the use of an anticoagulant. This error was also confirmed by an administrative nurse during an interview.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise the comprehensive care plans to reflect the current status of five residents. For Resident #17, the care plan did not include problems and interventions related to risk for malnutrition, actual weight loss, use of a diuretic, diabetes, and insulin use, despite a significant weight loss noted in the progress notes. Resident #27's care plan was not updated to reflect the discontinuation of IV Vancomycin, the addition of Doxycycline, and the care associated with the resident's cam boot. Resident #29's care plan still indicated continuous oxygen use, even though the oxygen was discontinued per physician's orders. Resident #35's care plan failed to identify nutrition risk, actual weight loss, use of a diuretic, diabetes, and use of oral hypoglycemic medications, despite significant weight loss and poor meal intakes documented in the progress notes. Resident #41's care plan did not reflect the nutrition risk and weight loss, use of diuretics, and the discontinuation of oxycodone and oxycontin, even though these changes were noted in the progress notes and physician's orders. An administrative nurse confirmed that care plans are expected to be updated with the resident's current orders, medication changes, and when new problems are identified. The failure to update the care plans limited the staff's ability to communicate care needs and ensure continuity of care for each resident. This deficiency was identified through record reviews, facility policy reviews, and staff interviews, highlighting a significant lapse in maintaining accurate and current care plans for the residents involved.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to promote care in a manner that maintained or enhanced residents' dignity for two residents who required assistance with dressing. Resident #14 was observed on multiple occasions wearing pants soiled with food debris, both in the dining room and in her room. Similarly, Resident #6 was observed wearing a shirt and pants soiled with food debris. The facility's policy on resident dignity, which aims to maintain the dignity and self-esteem of all residents, was not adhered to. An administrative nurse confirmed that staff are expected to change residents' clothing if soiled and ensure they are fully dressed after care.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident's physician of a significant change in condition for one of the sampled residents, specifically regarding weight loss. The facility's policy requires immediate notification to the physician for significant weight changes, defined as a 5% change in 30 days, 7.5% in 90 days, and 10% in 180 days. Resident #17, who had diagnoses including dementia and diabetes, experienced a weight loss that met these criteria. Despite this, the medical record lacked documentation of provider notification of the significant weight loss. The progress notes for Resident #17 indicated a series of weight measurements showing a decline from 176.5 pounds to 163 pounds over a period of 90 days, which constituted a 9.9% weight loss. The resident's Mini Nutritional Assessment (MNA) scores also declined, indicating a risk for malnutrition. An administrative nurse confirmed that the facility staff failed to notify the provider of the significant weight loss, which may have prevented the physician from altering the treatment or care provided to the resident.
Failure to Administer Insulin Within Prescribed Timeframe
Penalty
Summary
The facility failed to ensure staff followed standards of practice for administering intermediate-acting insulin to a resident. Specifically, a nurse administered 18 units of Humalog Mix 75/25 insulin to a resident at 5:19 p.m., but the resident did not receive their supper meal until 5:44 p.m., 25 minutes later. The prescribing information for Humalog Mix 75/25 insulin requires it to be injected within 15 minutes before a meal. An administrative nurse confirmed that staff are expected to administer intermediate insulin within this timeframe.
Failure to Follow Physician's Orders for CAM Boot and Foot Elevation
Penalty
Summary
The facility failed to ensure staff provided care and services for a resident with orders for a CAM Boot. The resident had a diagnosis of a nondisplaced trimalleolar fracture of the right lower leg and physician's orders to keep the right foot elevated every shift. However, observations throughout the survey showed multiple instances where the resident's right foot was not elevated while seated in a wheelchair or in bed. Additionally, the treatment administration record (TAR) and certified nurse aide (CNA) documentation did not indicate who was responsible for the application and removal of the CAM Boot or for elevating the right foot. During the survey, it was observed that CNAs and a nurse failed to elevate the resident's heels after transferring the resident to bed or performing wound care. An administrative staff member confirmed that nursing staff were expected to determine responsibility for following the order and to document it in the TAR or CNA Kardex. The facility did not provide care according to physician's orders, develop and follow the plan of care, or direct the staff responsible to document the removal/application of the orthopedic device.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident with significant weight loss. The facility's policy required weekly weights for the first four weeks following admission and re-weighing if weight varied by more than three percent. However, the staff did not weigh the resident weekly from mid-November to early December, resulting in a 52-pound weight loss, which represents a 27% decrease. The medical record did not identify the significant weight loss or its possible causes, and the staff failed to re-weigh the resident and document the conversation about the weight discrepancies. During an interview, the dietary manager and dietician acknowledged the failure to identify and address the resident's significant weight loss. The dietary manager recalled a conversation with nursing staff about the inaccuracy of the initial weights but admitted that no re-weighing or documentation occurred. This lack of adherence to the facility's policy and failure to monitor and reassess the resident's weight led to a delay in identifying and addressing the significant weight loss.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident remained free from unnecessary psychotropic medications. Specifically, the facility did not limit the use of a PRN psychotropic medication, Lorazepam, to 14 days as required by their policy. The physician's order for Lorazepam, dated October 2, 2023, did not include a rationale for its extended use or a stop date. This oversight was confirmed by an administrative nurse during an interview. The deficiency was identified as a repeat issue from a previous survey completed on May 25, 2023.
Failure to Follow Infection Control Standards
Penalty
Summary
The facility failed to follow infection control standards for three residents under enhanced barrier precautions (EBP). For Resident #17, a laundry aide applied alcohol-based hand rub (ABHR) to a gloved hand, entered the resident's room with clean laundry, and exited without removing the glove or performing hand hygiene. Additionally, a CNA assisted the resident without wearing gloves, placed soiled linens directly on the floor, and then placed a soiled blanket back on the bed without performing hand hygiene or donning clean gloves. These actions were contrary to the facility's policies on hand hygiene, glove use, and linen handling. For Resident #35, who had an unstageable pressure ulcer, two CNAs assisted the resident in transferring from a wheelchair to a toilet without donning gowns as required by EBP. One CNA removed a soiled brief, cleaned urine off the floor, and donned new gloves without performing hand hygiene. These actions violated the facility's policies on PPE use and hand hygiene. For Resident #195, who had a Stage II pressure ulcer, a nurse and a CNA entered the resident's room to provide care and transfer the resident without donning gowns, as required by EBP. This failure to follow the facility's policy on PPE use was confirmed during interviews with administrative nurses, who stated that staff were expected to adhere to the policies for handling linens, using gloves, and performing hand hygiene.
Failure to Assess Pneumococcal Status and Provide Education
Penalty
Summary
The facility failed to assess each resident's pneumococcal status and provide education regarding the benefits and potential side effects of the vaccination. Specifically, for one resident reviewed (Resident #17), the facility did not follow its policy to assess the resident's pneumococcal immunization status upon admission and provide the necessary education to the resident or their legal representative. This deficiency was identified through record review, policy review, and staff interviews during the survey process. The facility's policy, dated 09/21/23, mandates that upon admission, each resident or their representative should receive Vaccination Information Statements (VIS) for influenza and pneumococcal vaccines, and that the facility should review current vaccinations and document education on the benefits and potential side effects. However, Resident #17's medical record, reviewed during the survey, lacked evidence of such an assessment and education. An administrative nurse confirmed the failure to follow the policy for pneumococcal vaccine administration for this resident.
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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