St Catherines Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wahpeton, North Dakota.
- Location
- 1307 N 7th St, Wahpeton, North Dakota 58075
- CMS Provider Number
- 355033
- Inspections on file
- 21
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at St Catherines Living Center during CMS and state inspections, most recent first.
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.
Surveyors found that both the North and South Kitchens were not maintained in a clean and sanitary condition, with burnt and baked-on food debris in ovens, scattered food and debris on floors, dried food on cabinet surfaces, and mineral buildup and food debris under a handwashing sink. Debris, dust, and mineralization were also observed on top of the mechanical warewashing machine, and these conditions persisted across multiple observations, with additional debris created during oven cleaning. Two dietary staff members did not perform hand hygiene and handled the rims of beverage cups with bare hands while removing covers and arranging them on resident meal plates, contrary to FDA Food Code standards for preventing contamination of cleaned and sanitized utensils and lip-contact surfaces.
Surveyors found that staff failed to follow the facility’s hand hygiene and glove use policy during personal care and wound care for two residents. A CNA removed a wet brief, changed briefs, and performed perineal care without appropriate glove use or performing hand hygiene before, between glove changes, or after care. In a separate incident, a nurse provided wound care to a resident on enhanced barrier precautions for a chronic ulcer and suspected MRSA carrier status, entering and exiting the room without hand hygiene and performing the entire dressing change with the same soiled gloves, including handling clean dressings and supplies. An administrative nurse reported that staff were expected to perform hand hygiene with ABHR after resident care, between glove changes, and during dressing changes.
Surveyors found that two residents sharing a bathroom were exposed to persistent fecal soiling in the toilet bowl and on the toilet seat, along with an unlined trash can containing soiled wipes, despite a facility policy requiring regular cleaning of toilet surfaces and lined trash containers. Over repeated observations on multiple days, bowel movement residue remained present even after staff completed toileting care, and a resident reported that housekeeping had not cleaned the room or bathroom. Housekeeping staff reported being on-site daily, and administration stated that staff are expected to notify housekeeping or use sanitizing wipes after care, yet the bathroom remained unclean, failing to provide a safe, clean, and homelike environment.
Surveyors identified that a resident’s insulin pen label indicated a 10‑unit Lantus Solostar dose while nursing staff prepared and administered 12 units based on the eMAR, and an administrative nurse confirmed the label did not match the physician’s order. Facility policy stated that pharmacy should provide updated labels or a “see MAR for orders” label after dose changes, and that staff should follow the electronic order if pharmacy has not yet updated the label. In addition, a medication cart was observed unlocked and unattended on multiple occasions, despite facility policy requiring carts to remain locked when unattended, and an administrative nurse acknowledged the expectation that staff keep the cart locked.
A resident with peripheral vascular disease and recent COVID isolation developed wounds on the toes that were not consistently assessed, monitored, or documented according to facility policy and physician orders. The lack of timely treatment initiation, incomplete documentation, and poor provider communication led to delayed care, resulting in hospitalization and amputation of two toes due to gangrene.
A resident in a long-term care facility was verbally threatened by a CNA, causing fear and anxiety. The resident, who was cognitively intact and required assistance with daily activities, reported the incident, which was corroborated by another resident. The facility failed to recognize and address the abuse, as well as to update the care plan or notify the interdisciplinary team, leading to an immediate jeopardy situation.
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.
Unsanitary Kitchen Conditions and Improper Handling of Tableware
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain clean and sanitary conditions in both the North and South Kitchens, as required by the 2022 FDA Food Code. In the North Kitchen, observations showed burnt loose and baked-on debris in two ovens located under a stove, as well as scattered food and debris on the floors throughout the kitchen and in the mechanical warewashing room. On a subsequent observation, loose debris, dust, and mineralization were found accumulated on top of the mechanical warewashing machine, and the scattered food and debris remained on the floors in the kitchen and warewashing room. In the South Kitchen, surveyors observed burnt loose and baked-on debris in the double ovens, an approximately 14-inch linear area of dried food on the side of a silver lower cabinet, scattered food and debris on the floors throughout the kitchen, and mineral buildup and food debris under the handwashing sink. On later observations, the dried food on the cabinet and scattered food and debris on the floors and under the handwashing sink remained, with new debris present on the floor from cleaning the double ovens. Additionally, two unidentified dietary staff members failed to perform hand hygiene and touched the rims of water, juice, milk, and coffee cups with their bare hands when removing covers and arranging them onto resident meal plates, contrary to FDA Food Code requirements for preventing contamination of cleaned and sanitized utensils and lip-contact surfaces.
Failure to Follow Hand Hygiene and Glove Use Standards During Personal and Wound Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s hand hygiene policy and infection prevention standards during personal care for one resident. Observation showed a CNA transferring a resident to the toilet using a stand lift and removing the resident’s wet brief without wearing gloves. The CNA then applied gloves without performing hand hygiene, placed a clean brief on the resident, removed the gloves, and wiped her hands on her pants. Without completing hand hygiene, the CNA applied new gloves, performed perineal care, removed the gloves, assisted the resident back to bed, and exited the room without performing hand hygiene. The facility’s hand hygiene policy required hand hygiene before and after direct resident contact, when assisting with personal care and toileting, and after removing gloves. Surveyors also identified infection control failures during wound care for another resident who required enhanced barrier precautions due to a chronic right thigh ulcer, colostomy, and suspected MRSA carrier status. Observation showed a nurse donning a gown and gloves and entering the resident’s room without performing hand hygiene. The nurse obtained supplies from a dresser, placed them on the bedside table, removed the existing dressing from the right hip wound, and cleaned drainage from the wound. Without removing the soiled gloves, the nurse opened clean dressings, cleansed the wound with normal saline, patted it dry with gauze, and applied and taped a new dressing. The nurse then removed the gown and soiled gloves and exited the room without performing hand hygiene before entering or after exiting the room, and without changing gloves and performing hand hygiene between the soiled and clean portions of the dressing change. An administrative nurse stated she expected staff to perform hand hygiene with alcohol-based hand sanitizer after resident care, between glove changes, and during dressing changes.
Failure to Maintain Clean and Homelike Shared Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and homelike bathroom environment for two residents who shared a bathroom. The facility’s environmental services policy, dated 2020, required that the community be maintained in a clean and hygienic condition and that surfaces such as toilet seats be cleaned according to a schedule established by the environmental services supervisor, with community trash containers lined. Despite this policy, surveyors observed bowel movement (BM) splattered throughout the inside of the toilet bowl and smeared on the back and top of the toilet seat, as well as a trash can without a liner containing several soiled wipes next to the toilet. One of the residents reported that housekeeping had not cleaned the bathroom yet that day. Subsequent observations on multiple occasions over two days showed that BM remained in the toilet bowl and on the toilet seat, even after staff had reportedly completed toileting care for one of the residents in that same bathroom. The resident continued to report that housekeeping had not been in to clean the room or bathroom on either day. A housekeeping staff member stated that housekeeping staff are present seven days a week, and an administrative staff member stated she expects staff to notify housekeeping to address bathroom cleanliness or to clean areas with sanitizing wipes after care is provided. Nonetheless, the bathroom remained soiled over repeated observations, demonstrating a failure to ensure a clean and homelike environment as required by facility policy.
Medication Labeling Inconsistencies and Unsecured Medication Cart
Penalty
Summary
The deficiency involves failure to ensure accurate medication labeling and secure storage of medications. Surveyors observed that an insulin pen for Resident #3 was labeled for Lantus Solostar at 10 units in the morning, while a nurse prepared and administered 12 units, stating the provider had changed the order and that the correct 12‑unit dose was reflected in the electronic medication administration record (eMAR). Review of the eMAR confirmed a 12‑unit Lantus Solostar order with a start date of 11/17/2025. An administrative nurse later confirmed that the insulin pen label did not match the physician’s order in the eMAR and stated that insulin pen labels typically indicate “See MAR for dose,” and she expects staff to follow the eMAR. Facility policy on labeling of medications indicated that when a dose change occurs, pharmacy either sends a “see MAR for orders” label or a new label, and if pharmacy has not yet complied, nursing staff are to continue to administer the correct dose per the physician’s orders in the electronic record. The deficiency also includes failure to keep a medication cart locked when unattended. Surveyors observed a medication cart identified as #700 unlocked and unattended while a staff nurse was down the hallway. On another observation, the same medication cart was again found unlocked and unattended, and it remained so for eight minutes until an administrative nurse walked by and locked it. Review of the facility’s medication administration policy showed that the medication cart is required to be locked at all times when unattended. During interview, an administrative nurse stated she expects staff to lock the medication cart when it is not being attended.
Failure to Assess, Monitor, and Treat Foot Wounds Resulting in Amputation
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with impaired skin integrity on the feet and toes. Despite the resident's history of peripheral vascular disease and recent isolation for COVID, staff did not consistently assess, monitor, or document the resident's skin condition as required by facility policy. A physician's order was in place to monitor the wound every seven days and notify the physician if there was no change in two weeks, but the treatment administration record lacked documentation of skin assessment and treatment. Additionally, the electronic health record did not contain the dressing change orders referenced in the progress notes, and a weekly skin check failed to identify or assess the impaired skin integrity on the resident's toes. The facility also did not ensure timely initiation of treatment for the toe wounds, daily documentation of abnormal skin conditions, or proper communication with the provider regarding treatment. There was a lack of documentation from the physician assistant's in-house visit, and the administrative nurse confirmed that no assessment or orders were recorded from that visit. These failures resulted in a delay of treatment, and the resident was ultimately hospitalized for amputation of the fourth and fifth toes due to gangrene.
Failure to Prevent Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to provide an environment free of verbal abuse for a resident, leading to an immediate jeopardy situation. The incident involved a certified nursing assistant (CNA) who allegedly threatened a resident by saying, "If you don't stop talking about me, I'm going to put a pillow over your head and kill you." This statement was made after the resident had been put to bed, causing the resident to feel scared. The resident was cognitively intact and capable of making decisions, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The resident required assistance with activities of daily living, transfers, and had vision impairment and communication difficulties. The facility's investigation into the incident was initially deemed unsubstantiated, although it was acknowledged that a verbal altercation likely occurred. Another resident across the hall confirmed hearing yelling between the involved resident and the CNA. Additionally, other CNAs recalled conversations where the threatening statement was mentioned, but they did not report it to management. The facility failed to recognize the abuse, assess the resident physically and mentally, notify the interdisciplinary team, update the care plan, and inform the resident's provider. The facility's policy on abuse prevention, dated 2017, defines abuse as the willful infliction of intimidation resulting in mental anguish, including verbal and mental abuse. Despite this policy, the facility did not take appropriate action to prevent or address the verbal abuse incident, leading to fear, anxiety, and psychosocial harm for the resident involved.
Removal Plan
- CNA's file was updated to include do not rehire.
- All staff were retrained on definitions of abuse and how to identify abuse.
- Remaining facility staff were re-educated.
- The facility's regional registered nurse re-educated administrative staff members on definitions of abuse and how to identify abuse.
- Remaining administrative staff to be educated by administrative staff members.
- An automated notification was sent to all staff regarding the mandatory re-education.
- An education packet will be put in the employee newsletter for reference.
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.
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 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.
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 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.
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 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.
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 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
