St Gerard's Community Of Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Hankinson, North Dakota.
- Location
- 613 1st Ave Sw, Hankinson, North Dakota 58041
- CMS Provider Number
- 355038
- Inspections on file
- 15
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 2
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.
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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