St Vincent's - A Prospera Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Bismarck, North Dakota.
- Location
- 1021 N 26th St, Bismarck, North Dakota 58501
- CMS Provider Number
- 355060
- Inspections on file
- 22
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St Vincent's - A Prospera Community during CMS and state inspections, most recent first.
The facility failed to prevent abuse and neglect, as one resident experienced rough handling and emotional distress from CNAs, including being pulled by the neck and sustaining an undocumented bruise. Additionally, another resident with behavioral health issues repeatedly exhibited aggressive and inappropriate behaviors, such as verbal threats, swearing, and public urination, causing fear and anxiety among peers. The care plan did not address these behaviors, and staff were unaware of key incidents, resulting in an unsafe environment.
A resident with dementia and anxiety received frequent PRN Ativan administration for behaviors such as restlessness and agitation, without prior assessment of behavioral causes or implementation of non-pharmacological interventions. The care plan did not specify individualized strategies, and observations showed the resident was often unresponsive and required assistance for transfers, indicating a failure to prevent unnecessary use of psychotropic medication and chemical restraint.
Surveyors found that food was frequently served at unacceptable temperatures, with multiple residents reporting that their meals were cold or lukewarm, especially when delivered to rooms. Direct observations and a test tray confirmed that hot foods were not maintained at appetizing temperatures, in violation of facility policy.
Surveyors found thick black dust and dirt on fans, ceilings, and walls in the walk-in cooler and freezer, as well as peeling duct tape on an oven handle, making it non-cleanable. An administrative dietary staff member confirmed these unsanitary conditions and acknowledged staff responsibility for cleaning these areas.
The facility did not establish or maintain an effective QAPI process, resulting in ongoing deficiencies related to care plan revisions, nursing staff sufficiency, medication management, food quality and safety, and infection control. Despite administrative staff conducting audits and developing a plan of correction, these quality assurance activities did not prevent continued noncompliance.
Surveyors found that care plans were not updated or revised to reflect the current needs of several residents, including those with frequent behavioral issues requiring PRN medication, new skin lesions treated with antibiotics, aggressive behaviors and diabetes management needs, and a high risk for pressure ulcers due to wounds and immobility. These deficiencies limited staff communication and continuity of care.
The facility did not ensure adequate nursing staff to meet resident needs, resulting in multiple residents experiencing prolonged delays in call light responses, missed or delayed meals, and inadequate toileting assistance. Staff were observed not assisting residents as care planned, and documentation confirmed extended wait times for help, with some residents left in discomfort or unable to access their call lights. Staff interviews revealed high resident-to-nurse ratios and consistent staffing shortages, especially during shift changes and weekends.
A resident who required staff assistance for toileting was not provided timely help despite repeated requests, resulting in an incontinent episode in a public area. Staff did not follow the care plan for scheduled toileting and perineal care, and documentation showed significant delays between toileting opportunities.
Nursing staff conducted blood glucose checks and administered insulin injections to two residents in a common area, exposing them to observation by other residents and staff, rather than providing privacy as required by facility policy.
Facility staff did not ensure that a resident or their family representative was invited to participate in care conferences or informed of changes to the care plan, as required by facility policy. Medical records lacked documentation of invitations or involvement in care planning after admission, quarterly assessments, or hospitalizations, restricting the resident's right to provide input on care decisions.
The facility did not immediately report allegations of staff roughness and a resident-to-resident verbal altercation to the administrator or State Survey Agency, as required by policy. One resident and a family member described rough handling and disregard for requests, while another resident with cognitive and mental health diagnoses was involved in a threatening exchange with a peer. Facility staff failed to recognize and report these incidents as potential abuse.
The facility did not thoroughly investigate reports of staff roughness and a resident's injury during care, nor did it address a verbal altercation between two residents involving threats and profanities. Documentation lacked details of the allegations and investigations, and administrative staff were unaware of some incidents, resulting in a failure to protect residents and implement corrective actions.
Facility staff did not complete a significant change in status assessment (SCSA) for a resident who experienced a decline in activities of daily living and weight loss. The resident required increased assistance with oral hygiene and footwear, but staff did not identify or document the need for a SCSA as required by the RAI 3.0 guidelines.
Staff did not notify the primary care provider when a resident with type 2 diabetes had blood glucose readings above the ordered threshold, as required by physician orders. Documentation showed no evidence of provider notification for two critically high blood sugar results, and this was confirmed by administrative staff.
Two residents who required assistance with transfers were not provided with proper assessment or use of assistive devices, such as gait belts and mechanical lifts, as specified in their care plans. In one case, a CNA manually transferred a resident without a gait belt, and in another, staff used a sit-to-stand lift on an unresponsive resident without documented assessment of safety. Additionally, a resident fell during a van transfer when anti-rollbacks on the wheelchair were not properly positioned, resulting in the resident being lowered to the ramp floor. These incidents occurred due to lack of adherence to established policies and insufficient documentation or assessment by licensed staff.
A nurse failed to reconcile and report a discrepancy in the morphine sulfate count for a resident, as the narcotic count sheet showed remaining medication but the bottle was empty. Facility policy requires immediate reconciliation and reporting of such discrepancies for controlled substances, which was not followed in this case.
Staff failed to follow infection prevention protocols for two residents: one requiring Enhanced Barrier Precautions due to a urinary catheter, where a CNA did not wear a gown during high-contact care, and another with a history of UTIs, where perineal care was performed incorrectly and double briefing occurred. Administrative staff confirmed these practices did not meet facility policy.
The facility did not consistently post accurate daily nurse staffing information as required, with staffing reports on two survey days displaying incorrect dates. This failure was observed and confirmed through policy review and direct observation.
Failure to Protect Residents from Abuse and Inadequate Response to Aggressive Behaviors
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse, as evidenced by multiple incidents involving rough handling by certified nurse aides (CNAs). One resident, with diagnoses including vertigo and left-sided hemiplegia/hemiparesis, required substantial assistance for activities of daily living and was care planned for sit-to-stand lift transfers when experiencing vertigo. Despite this, the resident and a family member reported that some CNAs were rough during care, and that expressing concerns about this roughness led to even rougher treatment. Specific incidents included the resident's hands being hit against side rails and door frames during transfers, and being pulled to a sitting position by the back of the neck. The resident expressed fear of retaliation from a CNA and reported emotional distress about being a burden to staff. A bruise was observed on the resident's left hand, which the resident attributed to a transfer incident about a week prior, but there was no documentation of this injury in the medical record. An administrative nurse was aware of the abuse allegation but not the bruise. The facility also failed to protect residents from abuse by another resident who exhibited explosive outbursts and inappropriate behaviors. This resident, with a history of anxiety, stroke, dementia, and a mental disorder requiring continuous supervision, displayed repeated episodes of verbal aggression, swearing, urinating in inappropriate places in communal areas, and making threatening or demeaning comments to other residents. Progress notes documented multiple incidents where the resident's behavior caused distress and fear among other residents, including threats of physical violence, use of foul language, and inappropriate urination in front of others. Staff and other residents reported feeling unsafe and anxious due to these behaviors, and there were requests from residents and family members to file formal complaints. Despite the ongoing behavioral issues, the resident's care plan only addressed yelling and swearing at staff, with interventions limited to providing a calm atmosphere and redirecting the resident. The care plan did not address the resident's aggressive and inappropriate behaviors toward other residents. An administrative staff member was unaware of at least one significant incident and had not initiated an investigation until prompted. The facility did not adequately assess, monitor, or implement effective interventions to minimize the risk of abuse and protect residents from harm caused by this individual's behaviors.
Failure to Prevent Unnecessary Use of Psychotropic Medication and Chemical Restraint
Penalty
Summary
The facility failed to prevent the unnecessary use of psychotropic medications and did not ensure that a resident remained free from chemical restraints. A resident with diagnoses including vascular dementia, anxiety disorder, Alzheimer's disease, restlessness, and agitation was prescribed Ativan on a PRN basis for restlessness, agitation, and anxiety, with subsequent orders increasing the frequency and scheduling of the medication. Over a period of approximately 73 days, staff administered PRN Ativan 50 times for behaviors such as restlessness, agitation, rudeness to staff, refusing care, aggression, and wanting to leave the facility. Observations showed the resident was frequently unresponsive and asleep during the day, requiring physical assistance for transfers and toileting. The facility did not assess the resident's behaviors to determine causative or precipitating factors, nor did it develop a behavioral care plan or implement individualized non-pharmacological interventions prior to administering PRN Ativan. The care plan lacked specific details regarding the resident's behaviors and non-pharmacological strategies. Despite documentation from behavior and mood team meetings indicating no new concerns or improvements, the frequent use of Ativan continued, and the resident exhibited increased sleeping and decreased responsiveness.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
Surveyors identified that the facility failed to serve food at palatable and appetizing temperatures across three units. Review of facility policies confirmed that meals are required to be served at proper temperatures, with procedures in place for test tray monitoring to ensure compliance. Despite these policies, multiple resident interviews and direct observations revealed that both hot and cold foods were frequently served at temperatures that were not acceptable to residents. Several residents reported that their meals, especially when served in their rooms, were often cold or lukewarm, and one resident specifically noted that toast was always cold due to being prepared ahead of time. Observations also showed residents waiting for food to be reheated or expressing dissatisfaction with the temperature of their meals. A test tray conducted by surveyors further substantiated these concerns, with food items such as chicken, zucchini, and pasta measured at temperatures below what would be considered hot and appetizing. The surveyors themselves confirmed that the food was lukewarm rather than hot. These findings demonstrate a consistent failure to maintain food temperatures from preparation to service, resulting in meals that did not meet the facility's own standards for palatability and temperature.
Unsanitary Kitchen and Cold Storage Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain cold storage areas and kitchen equipment in a sanitary condition. Specifically, there was a significant accumulation of thick, dark black dust and dirt on the fans and surrounding ceiling and wall areas in both the walk-in cooler and freezer. Additionally, the handles of a reach-in oven were covered with peeling and tattered duct tape, creating a surface that could not be properly cleaned. These conditions were noted during both the initial and final observations of the kitchen. During an interview, an administrative dietary staff member confirmed the presence of the peeling duct tape on the oven doors and acknowledged that staff were expected to clean the black dust and dirt from the fans, walls, and ceilings in the walk-in cooler and freezer. The observations and staff confirmation indicate that the facility did not adhere to professional standards for food storage and equipment sanitation, as outlined in the 2022 FDA Food Code.
Failure to Implement Effective QAPI Process
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems, improve services and outcomes, and ensure compliance with federal requirements. Review of the facility's QAPI policy indicated that while the policy described using data to monitor services and identify improvement opportunities, the facility did not maintain compliance in several key areas, as evidenced by deficiencies cited during the last standard survey. These deficiencies included issues with care plan revisions, sufficient nursing staff, medication labeling and storage, palatable foods, food storage and preparation, and infection control. Interviews with two administrative staff members revealed that although they developed a plan of correction and conducted audits, the facility's quality assurance activities were not effective in preventing continued noncompliance in these areas.
Failure to Update and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of several residents, as required by policy. For one resident with dementia and anxiety, staff administered PRN Ativan 50 times over approximately 73 days for behaviors such as restlessness, agitation, aggression, and refusal of care, but the care plan did not specify these behaviors or detail appropriate non-pharmacological interventions. Another resident developed skin lesions and was prescribed topical and oral antibiotics, yet the care plan did not address these new skin issues or the use of antibiotics. A third resident, diagnosed with Alzheimer's disease, anxiety, and diabetes, exhibited aggressive and disruptive behaviors toward others and required insulin for diabetes management. However, the care plan did not address these behaviors or the management and complications of diabetes. Additionally, a resident with quadriplegia and an abdominal wound, identified as being at high risk for pressure ulcers, did not have a care plan that included problems, goals, or interventions related to the wound or pressure ulcer risk. These omissions limited staff communication and continuity of care.
Failure to Provide Sufficient Nursing Staff and Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations, interviews, and record reviews. Residents and family members reported frequent and prolonged delays in call light responses, with several residents waiting 30 minutes to an hour for assistance, particularly during shift changes, evenings, and weekends. Call light logs confirmed that some residents experienced wait times exceeding 20 minutes on numerous occasions, with the longest documented wait being 59 minutes. Residents also reported missed or delayed meals, lack of timely toileting assistance, and instances where call lights were not placed within reach, resulting in residents being unable to summon help when needed. Specific incidents included a resident who called the police due to excessive wait times for assistance, and another resident who was left in soiled incontinence products for several hours, despite care plans indicating the need for regular checks and changes. Observations showed staff instructing a resident to remain seated and not assisting with toileting, which led to the resident urinating on themselves and the floor. Documentation revealed that staff did not toilet the resident for nearly three hours, contrary to the care plan requirements. Staff interviews indicated that nurses were responsible for large numbers of residents per shift, sometimes up to 57, and that staffing levels did not vary between weekdays and weekends, except for bathing schedules. Administrative staff acknowledged expectations for call light response times to be under 15 minutes, or under 20 minutes during mealtimes, but evidence from logs and interviews demonstrated that these expectations were not consistently met. The facility's own assessment and policies emphasized the need for prompt response and adequate staffing, but these standards were not upheld in practice.
Failure to Provide Timely Toileting Assistance and Perineal Care
Penalty
Summary
Facility staff failed to provide appropriate toileting and perineal care for a resident who required staff assistance. The resident's care plan specified the need for check and change, use of incontinence products for heavy incontinence, and toileting every 2-3 hours and as needed. On the day of observation, the resident, who was seated in a wheelchair, expressed the need to use the bathroom multiple times and attempted to self-propel towards the restroom. Despite these requests, staff instructed the resident to remain seated and did not provide assistance to the bathroom. Subsequently, the resident experienced an incontinent episode, with urine running down the wheelchair and onto the floor in the activity room. Documentation showed the resident was last toileted over two hours prior to the incident and was not assisted again until nearly 40 minutes after the episode. An administrative nurse confirmed that staff are expected to toilet residents as care planned and as needed, but this did not occur in this instance.
Insulin Administration and Blood Glucose Checks Performed Without Resident Privacy
Penalty
Summary
Nursing staff failed to maintain resident dignity and privacy during the administration of insulin and blood glucose checks for two residents. On two separate occasions, a nurse performed blood glucose checks and administered insulin injections in the residents' abdomens in a commons area, where multiple residents and staff could observe the procedures. Facility policy requires that such procedures be conducted in a private area to respect residents' rights to privacy and dignity. An administrative nurse confirmed that staff are expected to take residents to a private area for these procedures.
Resident Not Included in Person-Centered Care Planning
Penalty
Summary
Facility staff failed to ensure that a resident and/or their family representative were given the opportunity to participate in the development and implementation of the resident's person-centered plan of care. Review of the facility's policy confirmed that residents and their surrogates have the right to make decisions regarding medical care and to be involved in care planning. However, medical record review showed no evidence that the resident or a family representative was invited to care conferences following admission, quarterly assessments, or after hospitalizations. An administrative nurse confirmed that care conferences are supposed to occur quarterly, after significant changes, and after hospitalizations, but documentation did not show that the resident or their representative was informed or included in these processes. As a result, the resident and/or their family representative were not afforded the opportunity to provide input or make decisions regarding changes to the resident's care, treatment, or interventions.
Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the administrator and to the State Survey Agency, as required by facility policy and state law. For one resident, allegations of staff being rough during care, grabbing the resident by the back of the neck, causing a bruise during a transfer, and disregarding call light requests were reported by the resident and a family member. However, an administrative nurse confirmed that these allegations were not reported to the state agency as required. Additionally, another resident with diagnoses including anxiety, stroke, dementia, and a mental disorder requiring continuous supervision was involved in a verbal altercation with another resident, during which both made threatening and abusive statements. Facility staff did not identify this incident as abusive behavior and failed to report it to the administrator or the State agency. An administrative staff member confirmed unawareness of the incident, indicating a lack of appropriate reporting and follow-up as outlined in facility policy.
Failure to Investigate and Address Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and incidents of resident-to-resident altercations. For one resident, there were reports from both the resident and a family member that staff were rough during care, including being grabbed by the back of the neck and sustaining a bruise to the hand during a transfer. The resident also reported that staff disregarded requests when responding to call lights. Although a CNA was placed on administrative leave following the abuse allegation, documentation did not include details of the allegation or the investigation process. An administrative nurse confirmed awareness of the allegations, but there was no evidence of a comprehensive investigation. Additionally, another resident with diagnoses including anxiety, stroke, dementia, and a mental disorder requiring continuous supervision was involved in a verbal altercation with another resident, during which threats and profanities were exchanged. The incident was documented in the medical record, but administrative staff were unaware of the event and no investigation was conducted. The facility did not ensure the protection of residents during the investigation process, nor did it implement or evaluate corrective actions related to these incidents.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
Facility staff failed to complete a significant change in status assessment (SCSA) for a resident who experienced a notable decline in condition. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, a SCSA is required when there is a major decline or improvement in a resident's status that affects more than one area of health and requires interdisciplinary review. In this case, the resident showed a decline in activities of daily living (ADLs), specifically requiring increased assistance with oral hygiene and taking on/off shoes and socks, as well as experiencing weight loss. Record review revealed that the resident's admission Minimum Data Set (MDS) indicated supervision was needed for oral hygiene and moderate/partial assistance for footwear. A subsequent quarterly MDS showed increased assistance was needed for both oral hygiene and footwear, along with documented weight loss. Despite these changes, there was no evidence that facility staff identified the need for or completed a SCSA following the resident's decline. An administrative staff nurse confirmed the resident's decline in these areas and the weight loss.
Failure to Notify Provider of Critically High Blood Glucose Levels
Penalty
Summary
Facility staff failed to follow professional standards of practice by not notifying the primary care provider when a resident with type 2 diabetes mellitus had blood glucose readings above the threshold specified in the physician's order. The order required staff to call the provider if blood sugar was less than 60 mg/dL or greater than 400 mg/dL. Medical record review showed that the resident had blood glucose readings of 567.0 mg/dL and 404.0 mg/dL on separate occasions, but there was no documentation that the provider was notified of these elevated levels. An administrative staff member confirmed that the physician was not notified as required by the order.
Failure to Ensure Safe Transfers and Supervision During Resident Handling
Penalty
Summary
The facility failed to provide adequate assessment and use of assistive devices necessary to prevent accidents for two residents who required assistance with transfers. In one instance, a certified nurse aide transferred a resident from bed to wheelchair and from toilet to wheelchair without using a gait belt, despite the care plan specifying its use. The resident verbalized weakness in her legs during the transfer, and the aide used manual support under the resident's arms and waist instead of the required device. In another case, two CNAs used a sit-to-stand mechanical lift to transfer a resident who was unresponsive and asleep, physically placing her hands on the assist bars. The medical record lacked documentation or assessment by a licensed nurse or therapy to confirm that this method of transfer was safe for the resident, and there was no completed sit-stand-walk data collection tool or assessment in the record. Additionally, the facility failed to provide appropriate supervision and assistance during a van transfer for a resident with multiple diagnoses, including abnormal posture, dementia, hemiparesis, and obesity. The resident's care plan required anti-tip bars on the wheelchair to be positioned upwards while going up and down the van ramp. During a transfer, the anti-rollbacks on the wheelchair caught the edge of the ramp, and the staff member was unable to hold the resident, resulting in the resident being lowered to the floor of the ramp. The staff member could not confirm if the resident hit his head, but the resident later reported possibly landing on the back of his head. The facility's failure to follow established policies and care plans regarding the use of assistive devices and proper supervision during transfers led to unsafe conditions and incidents involving residents who required assistance. The lack of proper assessment, documentation, and adherence to transfer protocols placed residents at risk of accidents and injury during both in-facility and van transfers.
Failure to Reconcile and Store Controlled Medications per Policy
Penalty
Summary
The facility failed to ensure accurate reconciliation and storage of medications for a resident during a medication pass. Specifically, a staff nurse was observed retrieving an empty morphine sulfate bottle for a resident, while the narcotic count sheet indicated that 4.25 ml of morphine sulfate should have remained in the bottle. This discrepancy was not immediately reconciled or reported as required by facility policy. Facility policy mandates that all controlled medications, including Schedule II drugs like morphine sulfate, must be verified and reconciled at each shift change. The policy requires the outgoing nurse to unlock the controlled medication storage, review the narcotic count book with the incoming nurse, and physically examine each medication for tampering or discrepancies. Any discrepancies or evidence of tampering must be reported to nursing management before the end of the shift. In this instance, the required reconciliation and reporting process was not followed.
Failure to Follow Infection Control and Perineal Care Protocols
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for two residents requiring enhanced precautions and perineal care. For one resident with an indwelling urinary catheter, the care plan required staff to use both gloves and a gown during high-contact care activities under Enhanced Barrier Precautions (EBP). However, during an observation, a certified nurse aide entered the resident's room, applied gloves but did not don a gown, and proceeded to empty the urinary drainage bag, contrary to facility policy and posted signage. Another resident, with a history of urinary tract infections and recent positive urine cultures, required staff assistance with perineal care. During observed care, a certified nursing assistant assisted the resident to the toilet and performed perineal cleaning using a washcloth, wiping from back to front, which is inconsistent with the facility's perineal care policy that specifies cleaning from front to back. Additionally, the resident was found wearing two briefs and a liner, which the CNA acknowledged was not permitted. Administrative staff confirmed that the expected infection control and perineal care procedures were not followed in both cases.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the accurate posting of daily nurse staffing information as required by its policy. On two out of four days during the survey, the posted staffing reports displayed incorrect dates: on one occasion, the report showed a date two days prior, and on another, it showed a date in the future. The facility's policy requires that staffing and resident census information be posted daily at the beginning of each shift and updated as appropriate. These discrepancies were observed during the survey and confirmed through review of the facility's policy and direct observation of the posted reports. No specific residents or staff were identified as being directly affected in the report, and no additional patient details or medical histories were provided.
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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