St Gabriel's Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Bismarck, North Dakota.
- Location
- 4580 Coleman Street, Suite 1, Bismarck, North Dakota 58503
- CMS Provider Number
- 355126
- Inspections on file
- 20
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at St Gabriel's Community during CMS and state inspections, most recent first.
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 bladder cancer, hematuria, and recent antibiotic use was not accurately coded on the MDS. The facility failed to document the cancer diagnosis, internal bleeding, and antibiotic administration in the appropriate MDS sections, as confirmed by staff interview.
Staff did not follow professional standards for insulin administration and failed to notify a physician when a resident's blood glucose readings were repeatedly above the ordered threshold. Additionally, a nurse was observed priming an insulin pen incorrectly, not in accordance with manufacturer instructions.
A resident with a history of constipation and impaired mobility did not receive required bowel management interventions after going several days without a bowel movement. Despite requesting prune juice, there was no documentation that nursing staff followed the facility's bowel protocol, leading to the resident being hospitalized for fecal impaction and a urinary tract infection.
A resident with dementia and a history of wandering exited the facility unsupervised after multiple documented episodes of confusion and exit-seeking behavior. Staff did not reassess the resident's elopement risk or update the care plan with individualized interventions, resulting in the resident being found off campus by a bystander.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) for two residents with indwelling Foley catheters, as required by facility policy. In both cases, staff assisted with resident transfers using gloves but failed to wear gowns during high-contact care activities, despite the expectation that gowns be used to prevent the transfer of MDROs.
The facility failed to follow infection control standards, with CNAs not performing hand hygiene between glove changes during resident care, and a nurse not donning appropriate PPE for a resident under Enhanced Barrier Precautions. These lapses were observed across multiple residents, indicating a breach in infection prevention protocols.
A resident with severe cognitive impairment repeatedly refused Ativan, an antianxiety medication, without the physician being notified. The facility lacked a policy for notifying physicians of medication refusals, and a family member expressed concern about the resident's ability to make informed decisions. A supervisory nurse was unaware if the physician had been informed of the refusals.
The facility failed to accurately code the MDS for three residents, affecting the reflection of their current status and needs. One resident's opioid medication was not coded, another's anticoagulant was incorrectly coded as an antiplatelet, and a third resident's hospice care was not recorded. Staff interviews confirmed these coding errors.
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.
Failure to Accurately Code MDS for Resident with Cancer and Hematuria
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one resident, as identified through record review, review of the RAI User's Manual, and staff interview. The resident had a history of hospitalizations for urinary tract infection and hematuria, with an active diagnosis of malignant neoplasm of the bladder and was prescribed Bactrim DS, an antibiotic. Despite this, the significant change and quarterly MDS assessments did not reflect the resident's cancer diagnosis in Section I0100, nor did they indicate internal bleeding in Section J1550D, even though hematuria was present. Additionally, the quarterly MDS failed to code the use of an antibiotic in Section N0415F. These omissions were confirmed during an interview with an MDS staff member, who acknowledged the failure to accurately code the MDS. The lack of accurate coding meant that the resident's assessment did not fully reflect their current status, as required by the RAI User's Manual guidelines for active diagnoses, health conditions, and medication use during the specified look-back periods.
Failure to Follow Insulin Administration Standards and Physician Notification Protocols
Penalty
Summary
Staff failed to follow professional standards of practice in the administration and management of insulin for two residents. For one resident with diabetes mellitus, physician orders required blood sugar checks three times daily and notification of the primary care provider if blood glucose exceeded 400 mg/dl or dropped below 70 mg/dl. Despite multiple documented instances where the resident's blood sugar readings were above 400 mg/dl, there was no documentation that staff notified the physician as required by the orders. Additionally, during observations of insulin administration for another resident, a nurse was seen priming an insulin pen horizontally, contrary to the manufacturer's instructions, which specify that the pen should be primed with the needle pointing up to ensure accurate dosing. The facility's policy and administrative nurse confirmed that staff are expected to follow these procedures and notify physicians of out-of-range blood sugar levels.
Failure to Follow Bowel Management Protocol Resulting in Fecal Impaction
Penalty
Summary
The facility failed to provide appropriate care and services for a resident at risk for constipation, as required by its bowel management protocol and standing house orders. The resident, who had a history of constipation and impaired mobility, did not have a bowel movement for over four days. Despite the facility's policy requiring specific interventions such as offering prune juice, administering Senna, and escalating to a bisacodyl suppository and provider notification if no bowel movement occurred, the medical record showed that these steps were not implemented. On the third day without a bowel movement, the resident requested prune juice, but there was no documentation that further protocol interventions were carried out after this request. Subsequently, the resident experienced an unresponsive episode, was found to be pale and hypotensive, and was transferred to the hospital, where they were diagnosed with a urinary tract infection and fecal impaction. The resident's bowel movement log confirmed no bowel movement occurred between the last recorded event and the hospitalization. An administrative nurse confirmed that the medical record lacked evidence of the required bowel management interventions being implemented prior to the resident's hospitalization.
Failure to Supervise and Monitor Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a known history of dementia and wandering, resulting in an elopement incident. The resident had multiple documented episodes of confusion, wandering, and exit-seeking behaviors, including looking for her car and attempting to leave the facility. Despite these behaviors, the facility did not reassess the resident's risk for elopement or update her care plan to include individualized interventions to prevent wandering and elopement. The initial care conference did not address the resident's wandering, and staff failed to recognize and respond to the resident's escalating risk. On the day of the incident, the resident exited the facility using her wheeled walker and was later found off campus by a bystander, who notified the facility. The facility's policy required evaluation of residents' potential for wandering upon admission and as needed, but there was no documentation of a reassessment or implementation of additional interventions after the resident began exhibiting wandering and exit-seeking behaviors. The lack of timely identification and response to the resident's risk for elopement placed all residents at risk for similar incidents.
Failure to Follow Enhanced Barrier Precautions During Resident Transfers
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy for two residents who required these precautions due to the presence of indwelling Foley catheters and, in one case, a chronic wound. According to the facility's policy, staff are required to use gowns and gloves during high-contact resident care activities, such as transferring residents or providing wound care, to prevent the transfer of multi-drug resistant organisms (MDROs). For one resident, after wound care was completed with appropriate PPE, a CNA removed her gown and gloves, performed hand hygiene, and applied new gloves, but then assisted with transferring the resident using a ceiling lift without donning a gown as required by EBP protocol. In another instance, two CNAs assisted a second resident, also on EBP due to an indwelling Foley catheter, to transfer from bed to wheelchair. The CNAs wore gloves but did not wear gowns during the transfer, contrary to the facility's EBP policy. An administrative staff member confirmed during an interview that staff are expected to wear gowns during high-contact care activities for residents on EBP. These observations demonstrate that staff did not consistently follow the established infection prevention and control procedures for residents requiring EBP.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, particularly in the use of personal protective equipment (PPE) and hand hygiene, for six residents. Observations revealed that certified nurse aides (CNAs) did not perform hand hygiene between glove changes during resident care activities. For instance, a CNA assisting a resident with toileting and personal care did not sanitize hands between multiple glove changes, potentially spreading contaminants. Similar lapses were observed with other residents, where CNAs failed to perform hand hygiene after handling urine collection bags and before touching other surfaces. In another instance, a CNA did not perform hand hygiene between glove changes while assisting a resident with perineal care and transferring them to a wheelchair. Additionally, a CNA was observed not changing gloves or performing hand hygiene after handling a resident's urine collection bag and before adjusting the resident in bed. These actions were contrary to the facility's hand hygiene policy, which mandates hand cleaning before and after direct resident contact and after handling soiled items. Furthermore, a staff nurse failed to don appropriate PPE when entering a resident's room under Enhanced Barrier Precautions (EBP). The nurse was unaware of the resident's precautionary status, indicating a communication lapse regarding resident care protocols. The administrative nurse confirmed the resident was still on EBP, highlighting a failure in ensuring staff compliance with infection control measures.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal of a prescribed medication, Ativan, which is used for anxiety and seizures. This deficiency was identified for one resident who had a pattern of refusing the medication. The lack of notification to the physician may have prevented necessary adjustments to the resident's treatment or care. The facility did not have a policy in place regarding the notification of physicians when a resident refuses medication. The resident involved had severe cognitive impairment, was sometimes understood, and had a history of rejecting care. Diagnoses included aphasia, anxiety disorder, dementia, and epilepsy. The resident refused Ativan on multiple occasions, specifically the 1:00 a.m. dose on several days and the 7:00 a.m. dose on one day. A family member expressed concern that the resident was unable to make informed decisions about medication refusal. A supervisory nurse acknowledged that the doctor should be informed of repeated refusals but was unaware if this had been done for the resident in question.
Inaccurate MDS Coding for Medications and Hospice Care
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which is crucial for reflecting their current status and needs. For one resident, the medical record indicated a physician's order for Tramadol, an opioid, but the quarterly MDS did not reflect this medication. A nurse manager confirmed that the opioid should have been coded on the MDS. Another resident's medical record showed a physician's order for Eliquis, an anticoagulant, but the MDS incorrectly coded it as an antiplatelet. An administrative nurse acknowledged the incorrect coding in Section N of the MDS. Additionally, the facility failed to code hospice care for a resident who had a hospice consult and was receiving hospice services, as noted in the care plan. The significant change MDS did not reflect the resident's hospice care status. A nurse manager confirmed that hospice care was not coded on the MDS, indicating a lapse in accurately capturing the resident's care needs.
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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