The Meadows On University
Inspection history, citations, penalties and survey trends for this long-term care facility in Fargo, North Dakota.
- Location
- 1315 S University Dr, Fargo, North Dakota 58103
- CMS Provider Number
- 355024
- Inspections on file
- 26
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Meadows On University during CMS and state inspections, most recent first.
A newly admitted resident did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The resident's assessment indicated needs for assistance with transfers and toileting, but the baseline care plan lacked interventions for these areas. An administrative staff member confirmed the omission.
A CNA did not follow infection control protocols for a resident with C. diff, failing to wear a gown, perform hand hygiene with soap and water, or assist the resident with hand hygiene after providing care. The CNA used hand sanitizer instead of washing hands as required by facility policy for contact precautions.
A resident with diabetes and malnutrition experienced significant weight loss due to staff failing to accurately monitor and document food and supplement intake, provide necessary encouragement and assistance during meals, and update the care plan to reflect the need for 1:1 meal support. Observations showed discrepancies between actual intake and recorded documentation, with supplements and meals often left unassisted and no alternative menu items offered when food was refused.
Multiple residents dependent on staff for ADLs were observed with untrimmed, dirty nails, inconsistent oral care, and inadequate assistance during meals. Staff failed to provide regular hygiene support and proper meal setup, resulting in residents struggling to maintain personal cleanliness and access food, despite care plans indicating the need for such assistance.
Surveyors observed that the kitchen was not maintained in a clean and sanitary condition, with dust and debris found on the warewashing machine, uncovered bowls, a dishware cart, and the floor in the dishwashing area. A dietary staff member confirmed that cleanliness standards were not met.
Staff failed to follow infection control standards during high-contact care activities, including not wearing required gowns for enhanced barrier precautions, improper glove use, and inadequate hand hygiene after perineal care and dressing changes. In several cases, staff did not retract the foreskin during male perineal care, and continued with other tasks without proper hand hygiene, increasing the risk of infection spread among residents.
Staff did not honor a resident's request to have a bladder scan before toileting cares and proceeded with care tasks against the resident's wishes. During the process, a CNA made an unprofessional comment, which the resident found inappropriate. Facility policy requires staff to treat residents with dignity and respect at all times, and the actions observed did not meet these standards.
A resident with quadriplegia was repeatedly left without access to a call bell that could be independently activated, despite a care plan specifying the need for specialized call bell placement. Staff were observed leaving the call bell out of reach after providing care, and the resident reported this occurred frequently. Facility policy and staff interviews confirmed the expectation that call bells should be accessible and usable by the resident.
Surveyors found that three residents' MDS assessments were inaccurately coded: one resident with serious mental illness was not coded as such, another with a suprapubic catheter was incorrectly coded for both indwelling and external catheters, and a third with Parkinson's Disease did not have this active diagnosis reflected in their MDS. These errors were confirmed by administrative and corporate staff.
A resident with impaired skin integrity and incontinence did not receive timely skin assessments or regular incontinence care as required by their care plan and physician's orders. Staff failed to document or treat multiple wounds on the resident's feet, and incontinence care was often provided only once or twice daily, leading to prolonged periods of wetness and increased risk for further skin breakdown.
A facility failed to administer rapid-acting insulin within the recommended timeframe for a resident, potentially risking a hypoglycemic reaction. Additionally, another resident with CHF did not receive their scheduled Lasix dose due to unavailability, which could exacerbate their condition.
A resident with limited mobility did not receive appropriate toileting and incontinence care, as evidenced by records showing infrequent check and change over a 29-day period. The resident reported long periods without changes, and an administrative staff member confirmed that the facility's expectation was for more frequent assistance.
The facility failed to serve meals at palatable temperatures to two residents. A CNA delivered a cold meal to a resident, who refused to eat it, and a nurse delayed serving a meal, resulting in a fish stick being served at 120.5°F. Another resident reported frequently receiving cold food. This failure may negatively impact residents' meal consumption.
The facility failed to follow infection control standards, as a staff member entered a resident's room without a mask despite influenza precautions, and a nurse did not perform hand hygiene after glove removal before assisting another resident with a meal.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the resident was admitted on 12/10/25, with a comprehensive assessment completed on 12/12/25 indicating the resident required assistance with transfers and toileting, but was independent with eating. However, the baseline care plan created on the admission date did not include interventions for the resident's specific needs related to transfers, eating, or toileting. An administrative staff member confirmed during interview that staff did not develop a baseline care plan for this resident as required by facility policy.
Failure to Follow Contact Precautions and Hand Hygiene for C. diff Resident
Penalty
Summary
A certified nursing assistant (CNA) failed to follow established infection prevention and control protocols for a resident diagnosed with enterocolitis due to Clostridioides difficile (C. diff), who was on contact/enteric precautions. Facility policy required staff to wear gloves and a gown upon entering the resident's room, perform hand hygiene with soap and water before and after glove use, and encourage or assist the resident with hand hygiene. During observation, the CNA entered the resident's room, donned gloves but did not wear a gown, and assisted the resident with a pivot transfer and toileting. The CNA did not perform hand hygiene after glove removal, instead using hand sanitizer, and did not encourage or assist the resident with hand hygiene as required by policy. The resident, who was independently able to complete toileting cares, was assisted by the CNA in transferring and ambulating within the room. The CNA failed to adhere to the facility's infection control policies regarding the use of personal protective equipment (PPE) and proper hand hygiene, specifically in the context of C. diff precautions, which require handwashing with soap and water. These actions were confirmed through observation, record review, and staff interview, indicating a lapse in following infection control standards for residents on contact precautions.
Failure to Monitor and Assist with Nutrition Leading to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a history of diabetes and malnutrition, resulting in significant weight loss. The resident experienced a 20% weight loss since admission, with documented weights showing a rapid decline over several months. Physician orders included a regular, easy-to-chew diet and scheduled nutritional supplements (Boost) three times daily and as needed for malnutrition. The care plan identified impaired physical functioning, the need for supervision at meals, and interventions such as encouraging food and fluid intake, recording meal percentages, and consulting a dietitian for caloric and nutritional needs. Despite these interventions, staff did not accurately monitor or document the resident's food and supplement intake. Multiple observations revealed discrepancies between actual consumption and what was recorded in the medical record and medication administration record (MAR). Staff frequently left supplements and meals unassisted, failed to provide encouragement, and did not offer alternative menu items when the resident refused food. The resident was often left alone during meals, and staff did not consistently provide the 1:1 assistance indicated by the interdisciplinary team (IDT). The MAR also showed that the resident did not receive any as-needed supplements during the survey period. The facility's records lacked a current dietitian evaluation addressing the significant weight loss and did not update the care plan to reflect the need for 1:1 meal assistance. Staff interviews confirmed expectations for accurate documentation and observation of intake were not met. The combination of inadequate monitoring, lack of assistance, and failure to implement care plan changes contributed to the resident's continued weight loss.
Failure to Provide Adequate Assistance with Personal Hygiene and Dining
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including personal hygiene and dining, for six residents who were dependent on staff support. Observations and record reviews revealed that multiple residents had untrimmed, dirty fingernails and toenails, and some had not received regular oral care. For example, one resident with paraplegia had long, thick, yellow toenails and stated that it had been a while since they were last trimmed. Another resident, dependent on staff for personal hygiene, had toenails approximately one-fourth inch in length and reported that staff only occasionally clipped them. Additional residents were observed with dirty fingernails, debris under their nails, and incomplete or irregular nail care, despite care plans indicating the need for staff assistance. Residents also experienced lapses in oral hygiene and assistance with meals. One resident with hemiplegia and hemiparesis was observed multiple times unable to reach or open items on their meal tray due to physical limitations, with staff failing to provide necessary setup or positioning assistance. This resident also reported inconsistent help with oral care, and was observed with visible debris on their face and mouth. Another resident was found with yellow-brown substance on their teeth and white crust at the corners of their mouth, and staff were observed using an unlabeled or incorrect toothbrush and basin, failing to ensure proper identification and hygiene supplies. Interviews with staff confirmed that CNAs were responsible for providing personal care, including nail and oral hygiene, but observations indicated that these tasks were not consistently performed as required by facility policy and individual care plans. The deficiencies were identified through direct observation, record review, and staff and resident interviews, demonstrating a pattern of inadequate assistance with ADLs for residents dependent on staff support.
Unsanitary Kitchen Conditions and Improper Dishware Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment as required by professional standards. Observations in the main kitchen revealed loose debris and dust on top of the mechanical warewashing machine, visible dry particles and debris on a tray of uncovered bowls located in a high traffic area, dry food and debris on the bottom of a cart used to store clean dishware, and an accumulation of food and dirt debris on the floor between the table legs of a stainless-steel counter and the wall in the dishwashing room. A dietary staff member confirmed that the kitchen environment and floors should remain clean.
Failure to Follow Infection Control Standards During High-Contact Care Activities
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices for several residents requiring enhanced barrier precautions (EBP) due to indwelling medical devices or wounds. In several instances, nursing staff performed high-contact care activities such as flushing Foley catheters and changing wound dressings without donning required gowns, despite clear facility policies and visible indicators (red dot stickers and PPE supplies) at resident rooms. Additionally, staff failed to follow proper glove use and hand hygiene protocols, such as not removing gloves or performing hand hygiene after handling soiled dressings or before obtaining clean supplies, and not changing gloves or performing hand hygiene between different care tasks. Certified nurse aides (CNAs) were observed providing perineal care and assisting with transfers without adhering to hand hygiene requirements. For example, after removing gloves post-perineal care, CNAs did not perform hand hygiene before proceeding to other tasks like adjusting clothing, handling personal items, or bagging linens. In one case, a CNA used soiled gloves to retrieve and apply barrier cream from a resident's nightstand, then continued with other tasks without proper glove change or hand hygiene. These lapses occurred despite the facility's policies and professional standards requiring hand hygiene after glove removal and between resident care activities. Further deficiencies were noted in the technique of perineal care for male residents. Staff failed to retract the foreskin during cleaning, as required to remove smegma and reduce bacterial growth, which was later observed by a nurse during catheterization preparation. Interviews with administrative nursing staff confirmed that the observed practices did not meet the facility's expectations for infection control during high-contact care activities, including the use of appropriate PPE and adherence to hand hygiene protocols.
Failure to Honor Resident Dignity and Respect During Cares
Penalty
Summary
Facility staff failed to provide care in a manner that maintained and respected the dignity and individuality of a resident with intact cognition. During an observed care event, two CNAs and a nurse transferred the resident from a wheelchair to bed in preparation for a bladder scan and toileting. Despite the resident's explicit request to have the bladder scan performed before toileting cares, staff did not honor this request and proceeded with rolling the resident and changing the brief before conducting the scan. Additionally, during the care process, one CNA made an unprofessional and inappropriate comment referencing her own body while rolling the resident. The resident later confirmed hearing the comment and expressed that it was not professional. Facility policy requires staff to treat residents with dignity and respect at all times, and an administrative nurse confirmed that both the failure to honor the resident's request and the CNA's comment were unacceptable.
Failure to Ensure Call Bell Accessibility for Resident with Quadriplegia
Penalty
Summary
Staff failed to ensure that a resident with quadriplegia consistently had access to a call bell that could be activated independently. The resident's care plan specified the use of an easy call universal quadriplegic call bell, which could be activated by turning the head, or a soft touch call bell placed in the resident's hand while in bed. Despite this, multiple observations showed that after staff exited the resident's room, the call bell was left out of reach, either in the seat of the wheelchair or clipped to the pillowcase in a way that the resident could not activate it. The resident, who was cognitively intact, reported that staff often failed to leave the call bell within reach or accessible for activation. Interviews with staff confirmed that the expectation was for the call bell to be placed within the resident's reach and to ensure the resident could activate it. The failure to follow these procedures resulted in the resident being unable to call for assistance as needed.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident with diagnoses including psychosis, schizotypal disorder, and bipolar disorder, the facility did not code the presence of a serious mental illness in Section A1510 of the MDS, despite documentation supporting the diagnosis. Another resident with a suprapubic catheter had their MDS coded for both an indwelling and an external catheter in Section H0100, contrary to the manual's instructions to code only as an indwelling catheter. Additionally, a resident with a documented diagnosis of Parkinson's Disease and a new medication order for carbidopa-levodopa did not have this active diagnosis reflected in Section I of their quarterly MDS. These inaccuracies were confirmed by administrative and corporate staff during interviews, who acknowledged the failures in proper MDS coding. The deficiencies were identified through review of medical records, physician orders, and provider notes, which demonstrated discrepancies between the residents' documented conditions and the information entered into the MDS assessments.
Failure to Provide Timely Skin and Incontinence Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with impaired skin integrity and incontinence. Despite a care plan and physician's orders indicating the need for weekly skin assessments and regular check and change assistance for incontinence, staff did not identify or document multiple areas of skin breakdown on the resident's toes and feet. Observations confirmed the presence of purple and red abrasion-type wounds with open areas on both feet, which were not recorded in the weekly skin assessments, treatment administration record, or physician's orders. The facility's policy required full assessment and documentation of skin breakdown, but this was not followed for the resident in question. Additionally, the facility did not provide a policy on the process or frequency of incontinence care for residents requiring check and change. Documentation showed that the resident often received incontinence care only once or twice in a 24-hour period, with only one day where care was provided four times. The resident reported long intervals between changes, sometimes remaining wet for extended periods, which required full bed changes. The lack of routine incontinence care and failure to monitor and treat skin issues in a timely manner contributed to the deficiency.
Failure to Administer Insulin Timely and Ensure Medication Availability
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering rapid-acting insulin to a resident. The manufacturer's instructions for Humalog insulin specify that it should be administered within 15 minutes before or immediately after a meal. However, a nurse administered 10 units of Humalog to a resident at 11:57 a.m., but the resident did not receive their meal until 12:56 p.m., 53 minutes after the insulin was given. This delay in meal service after insulin administration could potentially lead to a hypoglycemic reaction. An administrative nurse confirmed that the expectation was for meals to be served within 15 minutes of administering rapid-acting insulin. Additionally, the facility failed to ensure the availability of routine, regularly scheduled medication for another resident diagnosed with congestive heart failure (CHF). The resident was prescribed Lasix, a diuretic, to be taken in the morning for CHF management. However, on one occasion, the medication was not available, and the resident did not receive their scheduled dose. The medication was resumed the following day. An administrative nurse verified that the resident did not receive the Lasix as scheduled, which could potentially exacerbate the resident's CHF condition.
Inadequate Toileting and Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide appropriate toileting and incontinence care for Resident A, who required staff assistance with toileting and check and change. According to the resident's care plan, they had a physical functioning deficit related to limited mobility and required assistance with toileting. However, a review of Resident A's check and change record over a 29-day period revealed significant lapses in care. On four days, the resident was not checked and changed for 24 hours, on six days, they were checked and changed only once in 24 hours, on fifteen days, they were checked and changed twice, and on four days, they were checked and changed three times in 24 hours. During an interview, Resident A expressed that their incontinent product was not changed for long periods, which was corroborated by the check and change records. An administrative staff member stated that the expectation was for staff to assist residents with toileting and check and change every 2-3 hours and per resident request. The failure to adhere to these expectations resulted in a deficiency, as it placed the resident at risk for skin breakdown, poor hygiene, and other complications associated with inadequate incontinence care.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to serve foods at palatable temperatures for two sampled residents who received meal trays in their rooms. According to the facility's policy, ready-to-eat foods that require reheating should be cooked to at least 135 degrees Fahrenheit for hot service. However, observations revealed that a CNA delivered a noon meal to a resident, who spit out the fish and refused to eat, stating the food was cold and often received cold meals. The CNA replaced the tray with a new one. Another observation showed a nurse removed a meal tray from a conveyor cart and delayed serving it to a resident, resulting in the fish stick being served at 120.5 degrees Fahrenheit, which the resident described as barely warm. Additionally, a confidential resident reported frequently receiving cold food and needing to request reheating. This failure to serve foods at acceptable temperatures may negatively impact residents' meal consumption.
Infection Control Lapses in Influenza Precautions and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, specifically concerning influenza precautions and hand hygiene. One resident, who tested positive for influenza, was not properly isolated as a staff member entered the room without wearing a mask, despite the physician's orders for contact and droplet precautions. This oversight in following the facility's policy on transmission-based precautions could potentially lead to the spread of infection. Additionally, another resident with a Foley catheter was subject to improper hand hygiene practices by a nurse. After attempting to change the resident's catheter bag, the nurse removed her gown and gloves but did not perform hand hygiene before assisting the resident with their meal. This failure to follow the facility's hand hygiene policy after glove removal and before handling food further exemplifies the lapses in infection control practices within the facility.
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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