Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Gerard's Community Of Care during CMS and state inspections, most recent first.
Staff did not adhere to facility policy for insulin pen preparation and administration for three residents. Insulin pens were primed with the needle cap on, held horizontally, and in some cases, with an incorrect number of units, rather than following the required procedure of removing the cap, holding the pen upright, and dialing the correct dose.
Staff failed to consistently follow infection control protocols, including proper use of enhanced barrier precautions and hand hygiene, during high-contact care activities for three residents. Incidents included not wearing required PPE, not performing hand hygiene after glove removal, and not offering hand hygiene to residents during perineal and device care.
A resident with severe dementia engaged in unwanted physical contact with other residents, including kissing and touching, without their consent. The facility lacked adequate care plans and interventions to manage the resident's behavior and protect others. Staff failed to recognize and report these interactions as potential abuse, indicating a lack of awareness and training. The facility's policy required assessment and care planning for residents with behaviors that may lead to conflict, but this was not effectively implemented.
A facility failed to investigate incidents of resident-to-resident abuse involving three cognitively impaired residents. An Immediate Jeopardy situation was identified when a resident was observed engaging in inappropriate physical contact with others. Despite facility policy requiring immediate investigation of abuse, staff failed to report and investigate the incidents, leaving residents vulnerable to further harm.
The facility failed to protect 31 residents by not screening unlicensed employees prior to employment, placing them at risk for abuse, neglect, and exploitation. Despite a policy requiring background checks, the facility relied on applicants' honesty and community word-of-mouth instead of conducting thorough screenings. The administrator admitted the lack of a system to verify non-licensed staff's criminal history, leading to a deficiency in resident protection.
A facility failed to report incidents of resident-to-resident abuse involving residents with cognitive impairments. One resident was observed being touched by another despite family objections, and another resident with severe dementia was seen kissing and touching others without consent. Staff did not report these incidents to the administration or SSA, violating facility policy.
The facility failed to update care plans for two residents, impacting care delivery. One resident's plan lacked details on water restrictions related to medication and OCD, while another's plan omitted necessary transfer equipment, contrary to physician's orders. Observations confirmed these deficiencies, with staff interviews highlighting the need for individualized care plans.
The facility failed to provide adequate assistance during mechanical lift transfers for two residents, leading to potential risks of pain and discomfort. A resident with muscle weakness was improperly transferred using the EZ Way stand lift without the correct use of the seat strap, causing discomfort. Another resident with dementia was transferred without the required seat and leg straps. Additionally, the facility did not complete a thorough investigation for a resident with a history of falls and a recent fracture, failing to update the care plan and implement corrective actions.
The facility failed to ensure proper infection control practices, as observed with two CNAs who did not disinfect a sit-to-stand lift between resident uses and did not perform appropriate hand hygiene. One CNA acknowledged the failure to wash hands and change gloves during care, while another believed housekeeping was responsible for cleaning the lift.
Failure to Follow Insulin Pen Priming Protocols
Penalty
Summary
Staff failed to follow professional standards of practice for insulin pen preparation and administration for three residents. Facility policy required staff to prime the insulin pen by dialing 2 units, removing the needle cap, and holding the pen upright to ensure a drop of insulin appeared at the needle tip. However, observations revealed that a nurse primed insulin pens for two residents by dialing 3 units instead of 2, left the needle cap on, and held the pen horizontally rather than upright. Similarly, a medication aide primed an insulin pen for another resident by dialing the correct 2 units but also left the needle cap on and held the pen horizontally. These actions were directly observed during insulin administration for all three residents. During an interview, an administrative staff member confirmed that the expected practice was to prime the pen with the cap off and the needle pointed upward, as per facility policy. The failure to follow these procedures resulted in a deficiency related to not meeting professional standards of quality for medication administration.
Failure to Follow Infection Control Standards During Resident Care
Penalty
Summary
Surveyors identified failures in infection prevention and control practices for three residents during observed care activities. For one resident with a colostomy and catheter, a CNA donned appropriate PPE and performed hand hygiene after changing the colostomy bag, but a nurse who assisted with the procedure failed to apply a gown before providing care and did not perform hand hygiene prior to donning gloves. The facility's policy required enhanced barrier precautions, including gown and gloves, for high-contact care activities involving indwelling medical devices, which was not followed in this instance. Additional observations revealed that a CNA did not perform hand hygiene after removing soiled gloves and before applying a clean brief to another resident during perineal care. In a separate incident, a CNA assisted a resident with toileting, removed soiled gloves, and then applied clean gloves without performing hand hygiene, and also did not offer hand hygiene to the resident. These actions were inconsistent with the facility's infection control policies, which require hand hygiene after glove removal and between procedures.
Failure to Prevent Resident-to-Resident Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents with impaired cognition from resident-to-resident abuse, as evidenced by the interactions involving Resident #24 and other residents. Resident #24, who has a diagnosis of severe dementia and severely impaired cognition, was observed engaging in physical contact with other residents, including kissing and touching, without their consent. The facility did not have adequate care plans or interventions in place to manage Resident #24's behavior or to protect other residents from unwanted contact. Resident #24's care plan allowed for consensual acts of hand-holding and hugging in public areas, but it did not address the resident's behavior of entering female residents' rooms or the potential for unwanted physical contact. Despite previous incidents where Resident #24 entered rooms and engaged in physical contact, the facility did not update the care plan to include interventions to prevent such behavior. Additionally, staff failed to recognize and report these interactions as potential abuse, indicating a lack of awareness and training on identifying and managing resident-to-resident abuse. The facility's policy on abuse, neglect, and exploitation required staff to assess, monitor, and develop appropriate care plans for residents with behaviors that may lead to conflict. However, the facility did not have a system in place to assess all residents' needs and preferences, resulting in inadequate care planning and monitoring. This oversight led to multiple incidents where residents with impaired cognition were subjected to unwanted physical contact, causing potential fear, anxiety, and psychosocial harm.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate incidents of resident-to-resident abuse involving three residents with impaired cognition who were unable to consent. During the on-site recertification survey, an Immediate Jeopardy (IJ) situation was identified when a nurse's note revealed that a resident had kissed two female residents on the cheek. An observation showed the same resident engaging in inappropriate physical contact with another resident, who remained non-verbal throughout the incident. These actions placed the residents in immediate danger of fear, anxiety, or psychosocial harm. The facility's policy on abuse, neglect, and exploitation requires immediate investigation when abuse is suspected or reported. However, the staff failed to report and investigate the incidents involving the resident's inappropriate behavior. Interviews with staff and family members revealed that the facility was aware of the resident's behavior but did not take appropriate action to prevent further incidents. The family of one resident had explicitly stated they did not want the resident to be touched, but their wishes were not respected. The medical records of the involved residents indicated severe cognitive impairments, making them vulnerable to abuse. Despite this, the facility did not recognize the resident's actions as abuse and failed to report them to the appropriate authorities. The lack of reporting and investigation prevented the facility from protecting the residents from further harm and addressing the behavior of the resident involved.
Failure to Screen Unlicensed Employees for Abuse and Neglect
Penalty
Summary
The facility failed to protect all 31 residents by not screening unlicensed employees prior to employment, which placed residents at risk for abuse, neglect, exploitation, and misappropriation of property. The facility's policy, revised in June 2023, mandates the screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes conducting background, reference, and credentials checks on potential employees, contracted temporary staff, students, volunteers, and consultants. However, the facility did not adhere to this policy, as evidenced by the administrator's admission that criminal history checks were not conducted on unlicensed employees or new hires. Instead of conducting thorough background checks, the facility relied on applicants' honesty regarding felony convictions on their application forms and community word-of-mouth in their small-town setting. The administrator acknowledged the lack of a system to screen non-licensed staff to ensure they have not been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This oversight in the facility's hiring process was identified during a survey, which reviewed the facility's CMS Matrix showing 31 residents and highlighted the deficiency in protecting residents from potential harm.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report incidents of resident-to-resident abuse to the Administrator and State Survey Agency (SSA) for three residents with cognitive impairments who were unable to consent. The facility's policy requires staff to notify their department supervisor immediately upon witnessing or having reliable knowledge of any act of abuse. However, this protocol was not followed in several instances involving residents with dementia and Alzheimer's disease. One incident involved a resident with dementia who was observed being touched and held by another resident, despite her family's explicit instructions against such contact. The family had initially consented to limited physical contact but later withdrew their consent due to the other resident's escalating behavior. The staff member who was informed of the family's wishes failed to recognize the situation as abuse and did not report it to the administrator. Another incident involved a resident with severe dementia who was observed kissing and touching other residents without their consent. Despite witnessing these actions, a nurse did not report the incidents to the Director of Nursing, administrator, or abuse coordinator, as required by the facility's policy. The administrative staff confirmed they were not notified of these behaviors, and the facility lacked evidence that the incidents were reported to the appropriate authorities.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of two residents, leading to deficiencies in care. For one resident with traumatic brain disorder and epilepsy, the care plan stated 'no water in room,' but did not specify the times when water should be provided or the reason for this restriction. Observations showed that the resident did not have a water cup in the room and had to request water, with staff indicating that water intake was restricted due to medication and obsessive-compulsive disorder. However, the care plan lacked details on the specific times and reasons for water restrictions, limiting staff's ability to ensure proper hydration management. Another resident with osteoarthritis had a care plan indicating the use of an EZ stand lift with one staff assist for transfers, but it failed to include the use of a buttocks sling and leg strap as per physician's orders. An observation revealed that a CNA transferred the resident without using the required equipment, which was not reflected in the care plan. An administrative nurse acknowledged the expectation for individualized care plans, highlighting the facility's failure to update the care plan to include necessary transfer equipment, potentially compromising the resident's safety during transfers.
Inadequate Assistance and Investigation in Resident Transfers
Penalty
Summary
The facility failed to provide adequate assistance during mechanical lift transfers for two residents, leading to potential risks of pain and discomfort. Resident #3, diagnosed with muscle weakness and arthritis, was observed being transferred using the EZ Way stand lift without proper use of the seat strap. The resident was unable to bear weight and hung from the chest harness, causing the harness straps to pull upward into the axillae, raising the shoulders to ear level. This improper use of the lift was observed on two separate occasions, with the CNA failing to position the seat strap correctly under the buttocks. Resident #10, diagnosed with dementia and osteoarthritis, was also transferred using the EZ Way stand lift without the application of the seat/buttocks and leg straps, as required by the physician's order. This oversight during the transfer process further exemplifies the facility's failure to adhere to proper procedures, potentially compromising the resident's safety and well-being. Additionally, the facility did not complete a thorough investigation for Resident #4, who had a history of falls and a recent fracture. Despite experiencing seven falls within a two-month period, including one with a major injury, the facility failed to update the care plan since 2020 and did not implement a corrective action plan. The administrative nurse confirmed the lack of a completed investigation and corrective measures, indicating a significant oversight in addressing the resident's fall risk and ensuring their safety.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a certified nurse aide (CNA #4) who did not adhere to proper hand hygiene and equipment disinfection protocols. During an observation, CNA #4 was seen transferring a resident using a sit-to-stand lift without cleaning or disinfecting the equipment between uses. Additionally, the CNA did not perform hand hygiene after removing soiled gloves and before touching clean items, such as the resident's blanket and sheets. The CNA acknowledged the failure to wash hands and change gloves appropriately during care. Another observation revealed that a different CNA (#8) also did not disinfect the sit-to-stand lift after assisting a resident to the bathroom. During an interview, CNA #8 stated that she does not clean the lift between uses, as she believed housekeeping was responsible for this task. The Director of Nursing (DON) confirmed that staff should wash their hands before and after resident care and clean equipment between each use to prevent infection spread.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hankinson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Catherines Living Center | 20.3 mi | ★★★★★ | 6 | 0 |
| St Francis Home | 20.5 mi | ★★★★★ | 7 | 0 |
| Traverse Care Center | 26.9 mi | ★★★★★ | 7 | 0 |
| Tekakwitha Living Center | 28.5 mi | ★★★★★ | 15 | 0 |
| Browns Valley Health Center | 32.9 mi | ★★★★★ | 7 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.