Western Horizons Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hettinger, North Dakota.
- Location
- 1104 Hwy 12, Hettinger, North Dakota 58639
- CMS Provider Number
- 355042
- Inspections on file
- 21
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Western Horizons Care Center during CMS and state inspections, most recent first.
A resident with dementia and impaired cognition eloped from the facility due to non-functioning door alarms, resulting in injuries and mild hypothermia. The resident exited through an emergency door without triggering the alarm, as it was not engaged. The facility's investigation revealed that two of six emergency exit door alarms were not engaged, and there was a lack of documentation for weekly alarm function tests.
A resident with a history of sexually inappropriate behavior engaged in unwanted sexual contact with another resident who had severe cognitive impairment. The incident was witnessed by a staff member who intervened but was unsure if it was reported. The facility's policy on abuse was not followed, and the incident was not documented in the affected resident's medical record.
A resident with a history of inappropriate behavior was observed touching another resident inappropriately. The incident was documented but not reported to the SSA as required by facility policy. An administrative nurse was unaware of the incident, confirming it was not reported, placing all residents at risk.
The facility failed to maintain sanitary conditions in food preparation and storage areas, with issues in sanitizer solution concentration and food labeling. Observations showed multiple undated and unlabeled food items in the kitchen and kitchenettes, contrary to facility policy. Dietary staff confirmed the expectation for proper labeling and discarding of outdated food items.
The facility failed to provide the required air gap for two multi-compartment sinks in the main kitchen, as per the 2018 North Dakota Plumbing Code. The drainpipes of a two-compartment sink and a three-compartment sink were joined and ended below the floor drain rim, risking contamination. Dietary staff used these sinks for food prep and thawing, while maintenance staff noted a plumber's recent work on the drainpipe.
The facility failed to maintain an effective pest control barrier, resulting in the presence of flies, gnats, ants, and a centipede in the kitchen and dining room. Observations included flies on clean glasses and gnats in the food prep area. Interviews with a resident and staff confirmed ongoing pest issues, including a mouse found in a sticky trap. The back door was improperly fitted, and an open window without a screen was noted.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. The resident was found with unlabeled medications in an open bedside drawer, and their medical record lacked an assessment or physician's order for self-administration. An administrative nurse confirmed the oversight.
A facility failed to ensure a resident and/or their representative completed the SNFABN for the termination of Medicare Part A services. The SNFABN did not indicate whether the resident or their representative chose to continue services, discontinue services, or request a demand bill. Additionally, the resident's medical record lacked documentation of their decision regarding the continuation of services with personal payment responsibility or discontinuation upon the end of Medicare Part A coverage.
The facility inaccurately coded the MDS for two residents, indicating incorrect medication administration during the look-back period. An administrative nurse confirmed the errors, which could impact care planning and delivery.
The facility failed to accurately complete a PASARR screening for a resident, omitting diagnoses of PTSD and bipolar disorder. The resident's medical record included these diagnoses, but they were not reflected in the Level 1 PASARR screening completed prior to admission. An administrative staff member acknowledged that provider diagnoses should be correctly reviewed and entered.
The facility failed to update care plans for three residents, impacting communication and continuity of care. A resident with breast cancer experienced significant weight loss without corresponding care plan updates. Another resident, observed without dentures, was identified as malnourished, yet lacked nutritional interventions in their care plan. A third resident's care plan did not address diabetes, diuretic use, anemia, and weight loss. Staff confirmed the care plans were not reviewed or revised timely.
A facility failed to maintain safe flooring, as a torn and raised strip of laminate was observed in front of a resident's recliner. The resident, with a history of falls, reported the flooring had been in disrepair for some time and often self-transfers despite needing assistance. An administrative staff member confirmed the need for repair.
The facility failed to identify trauma history and triggers for two residents with PTSD. One resident's record included a PTSD diagnosis and medication for related symptoms but lacked a trauma assessment and care plan. Another resident's care plan did not identify triggers or interventions despite a PTSD diagnosis. An administrative staff member confirmed the expectation for staff to assess potential triggers, which was not fulfilled.
A resident with ill-fitting dentures did not receive necessary assistance from the facility to obtain dental care, as required by policy. The resident was observed without dentures, had documented chewing difficulties, and experienced significant weight loss. Despite expressing a desire for new dentures, there was no documentation of appointment refusals, and the last dental exam was over a year ago. Interviews with staff confirmed the resident's prolonged lack of dentures.
The facility failed to communicate and document the allergens and food preferences of two residents, as required by its policies. One resident's preference to avoid certain vegetables was not recorded, and another resident's mushroom allergy was not noted on their diet card, despite being known by dietary staff.
A resident was placed at risk when a CNA used a hair dryer while the resident was in a tub full of water, violating the facility's safety policy. The incident was reported by the resident's family, leading to an investigation that confirmed the CNA's failure to follow safety practices.
Resident Elopement Due to Non-Functioning Door Alarms
Penalty
Summary
The facility failed to ensure the safety of a resident who eloped from the building, resulting in injuries. The resident, diagnosed with dementia and adjustment disorder, was identified as having severely impaired cognition and was at high risk for elopement and falls. Despite wearing a wander guard, the resident managed to exit the facility through an emergency door without triggering the alarm, as the alarm was not engaged. The resident was found outside in cold weather, inadequately dressed, and sustained multiple abrasions and mild hypothermia. The incident occurred when the resident exited his room and left the building through an emergency exit door. The door alarm failed to sound, allowing the resident to leave unnoticed. The facility's camera footage confirmed the resident's movements and the failure of the alarm system. The resident was later found by a community member and transported to the emergency room for evaluation and treatment of his injuries. Further investigation revealed that two of the six emergency exit door alarms were not engaged, and the facility lacked documentation of weekly alarm function tests. Additionally, a staff member admitted to noticing issues with the alarms but failed to replace the batteries in a timely manner. This oversight contributed to the resident's ability to elope from the facility undetected.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from unwanted sexual contact by another resident, leading to a deficiency in ensuring residents remain free from abuse. The incident involved a resident with a history of sexually inappropriate behavior towards female staff and residents. Despite being identified as having moderate cognitive impairment and being independent for ambulation, this resident was noted to have placed his hand on the upper leg and crotch of another resident, who had severe cognitive impairment. This inappropriate contact was witnessed by a staff member who intervened by removing the resident's hand and separating the two residents. The facility's policy on abuse, neglect, and exploitation, which emphasizes the right of residents to be free from abuse, was not adhered to in this instance. The administrative nurse was unaware of the incident, and the staff member who witnessed the event was unsure if it was reported. The medical record of the resident who experienced the unwanted contact lacked documentation of the incident, indicating a failure in communication and documentation processes within the facility.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the State Survey Agency (SSA) as required by their policy. The incident involved a resident with dementia, adjustment disorder, mood disturbance, and anxiety, who was identified as having moderate cognitive impairment and a history of being sexually inappropriate. This resident was observed placing his hand on the upper leg and crotch of another resident, who had severe cognitive impairment and diagnoses of depression and anxiety. The incident was documented in a progress note but was not reported to the facility administrator or the SSA. The facility's policy on abuse, neglect, and exploitation mandates that all alleged violations involving abuse must be reported to the administrator and the SSA within 24 hours. However, the administrative nurse interviewed was unaware of the incident, confirming that it had not been reported as required. This oversight placed all residents at risk for possible abuse, as the facility did not follow its own procedures for reporting and addressing such incidents.
Sanitation and Food Labeling Deficiencies in Kitchen Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation and storage areas, as observed in one kitchen and two kitchenettes. During an interview, a dietary staff member revealed that the sanitizer solution used for cleaning food preparation areas was not functioning properly, as the automatic dispenser had parts replaced recently, and the sanitizer bucket contained only hot water. This failure to ensure the proper concentration of the sanitizer solution could compromise food safety. Additionally, the facility did not adhere to its policy on food receiving and storage, which requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Observations revealed multiple instances of food items, such as cranberry juice, sandwiches, pies, noodles, cod, churros, bread dough, garlic bread, donuts, chicken cordon bleu, chicken strips, fish sticks, corn dogs, and pork patties, that were either undated, unlabeled, or stored in unsealed bags. Dietary staff members confirmed the expectation for staff to label and date food items when opened and to discard outdated food items, which was not being followed.
Deficiency in Kitchen Sink Air Gap Compliance
Penalty
Summary
The facility failed to provide the required air gap for two multi-compartment sinks in the main kitchen, as observed during the survey. According to the 2018 North Dakota Plumbing Code, an air gap is necessary to prevent contamination in the event of a sewer back-up. The survey revealed that the drainpipes of a two-compartment sink and a three-compartment sink were joined and ended approximately two inches below the rim of a cut-out in the tiled flooring containing the floor drain, which did not meet the code's requirement for an air gap. Interviews with dietary staff members revealed that the three-compartment sink was used for thawing items in water and draining vegetables, while the two-compartment sink was used for food preparation. A maintenance staff member reported that a plumber had recently worked on the drainpipe and indicated that the current setup was necessary. However, this configuration did not comply with the plumbing code, leading to the deficiency noted in the report.
Pest Control Deficiency in Kitchen and Dining Room
Penalty
Summary
The facility failed to maintain an effective pest control barrier in the kitchen and one of the dining rooms, leading to the presence of pests such as flies, gnats, ants, and a centipede. Observations revealed flies walking across clean glasses and gnats flying in the food prep area. Dead flies and gnats were found on the window ledge and floor, and a large winged bug was observed near the ice machine. Ants and a centipede were seen crawling on the dining room floor, and flies were noted on a menu plan above the food during the evening meal. Additionally, gnats were observed near plants at the facility entrance, and an open window without a screen was found in the dining room entrance, with visible gaps between the door and frame. Interviews with residents and staff highlighted the ongoing pest issues. A resident reported an ant and fly problem in the dining room, while a dietary staff member confirmed the presence of bugs, flies, gnats, and mice, noting a mouse was found in a sticky trap the previous week. The back door was reported to not fit the foundation properly, allowing dirt to come through. A maintenance staff member mentioned that delivery personnel often leave the kitchen entrance door open and planned to replace the weather strip on the door to the outside, acknowledging the presence of a mouse earlier in the year.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, as observed during a survey. The policy in place required an interdisciplinary team to determine the safety of self-administration for each resident, and this should be documented in the care plan. However, the resident was found with unlabeled medications, including two types of eye drops and a vapor rub, in an open bedside drawer. The resident's medical record did not contain an assessment or a physician's order for self-administration of these medications. An administrative nurse confirmed the lack of assessment and physician's order, acknowledging the facility's failure to evaluate the resident's capability to self-administer medications safely.
Failure to Complete SNFABN for Medicare Part A Termination
Penalty
Summary
The facility failed to ensure that a resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for the termination of Medicare Part A services. This deficiency was identified for one of the three residents reviewed, specifically for a resident who was discharged from Medicare Part A on March 20, 2024. The SNFABN did not indicate whether the resident or their representative chose to continue services, discontinue services, or request a demand bill. Additionally, a review of the resident's medical record on July 24, 2024, revealed a lack of documentation indicating the resident's or representative's decision regarding the continuation of services with the understanding of personal payment responsibility or the discontinuation of services upon the end of Medicare Part A coverage. This oversight limited the resident's or representative's ability to exercise their rights concerning Medicare Part A services.
Inaccurate MDS Coding for Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which is essential for reflecting each resident's current status and needs. For one resident, the annual MDS indicated that the resident received an antidepressant and antibiotic during the seven-day look-back period, but the medical record did not support this. Similarly, for another resident, the quarterly MDS indicated the administration of an antianxiety medication, which was not documented in the medical record. Additionally, the Medicare five-day MDS for the same resident incorrectly indicated the administration of a hypnotic, which was also not supported by the medical record. During an interview, an administrative nurse confirmed that the staff had incorrectly coded Section N of the MDS for both residents. This inaccuracy in the MDS coding could potentially affect the development of a comprehensive care plan and the care provided to the residents, as the assessments did not accurately reflect the residents' medication usage during the specified period.
Inaccurate PASARR Screening for a Resident
Penalty
Summary
The facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASARR) for a resident reviewed with PASARR services. The deficiency was identified during a record review and staff interview. The resident's medical record included diagnoses of dementia, anxiety, dissociative identity disorder, major depression, PTSD, and bipolar disorder. However, the Level 1 PASARR screening completed by the facility prior to admission did not include the resident's diagnoses of PTSD and bipolar disorder. During an interview, an administrative staff member stated that provider diagnoses should be reviewed and entered correctly on the PASARR screening.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans for three residents, which limited staff's ability to communicate needs and ensure continuity of care. Resident #3, diagnosed with malignant neoplasm of the right breast, experienced significant weight loss, yet their care plan lacked problems, goals, and interventions related to this issue. An administrative staff member confirmed the oversight during an interview. Resident #9, who was observed without dentures, had a care plan that did not include nutritional interventions despite being identified as malnourished. The resident expressed dissatisfaction with ill-fitting dentures, and a CNA confirmed the resident had been without dentures for a long time. Resident #36's care plan was also found lacking, as it did not address issues related to diabetes, diuretic use, anemia, and excessive weight loss. The resident's medical record included diagnoses of chronic kidney disease, hypertension, edema, diabetes, altered mental status, and anemia. An administrative staff member confirmed that the care plans had not been reviewed or revised in a timely manner, contributing to the deficiency in care planning for these residents.
Deficiency in Maintaining Safe Flooring
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by a torn and raised strip of laminate flooring in front of a resident's recliner. This condition was observed during a survey, and the resident confirmed that the flooring had been in disrepair for some time. The resident, who has a history of falls, mentioned that he should ask for assistance but often self-transfers from the recliner to the wheelchair. An administrative staff member acknowledged the need for flooring replacement.
Failure to Identify Trauma Triggers for Residents with PTSD
Penalty
Summary
The facility failed to identify a history of trauma and trauma triggers for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident #4's medical record included a diagnosis of PTSD and a physician's order for Venlafaxine HCI ER to manage depression and anxiety related to PTSD. A psychiatry provider note indicated symptoms such as poor concentration, irritability, and depression following a traumatic brain injury. However, the medical record lacked a trauma assessment, identification of potential triggers, and a trauma care plan. Similarly, Resident #31's medical record identified a diagnosis of PTSD in the Minimum Data Set, but the care plan did not include triggers or interventions to prevent re-traumatization. A psychiatry provider note confirmed a past medical history of PTSD, yet the record did not contain a trauma assessment or potential triggers. An administrative staff member confirmed that they expected staff to interview the resident or family and review psychiatric notes for potential triggers related to PTSD, which was not done.
Failure to Assist Resident with Dental Care
Penalty
Summary
The facility failed to assist a resident with obtaining necessary dental care for ill-fitting dentures, which was a requirement according to their policy. The policy stated that social services personnel were responsible for helping residents make dental appointments and arrange transportation as needed. Despite this, the resident was observed without dentures throughout the survey period, and the medical record indicated issues with chewing and a significant weight loss over 180 days. The resident expressed a desire for new dentures, and a CNA confirmed that the resident had been without dentures for a long time. The facility's records lacked documentation of the resident's refusal of appointments, as mentioned by an administrative staff member. The resident's last dental exam was noted to have occurred over a year prior, and a recent oral/dental assessment highlighted the need for dental care. Additionally, a mini nutritional assessment identified the resident as malnourished, further emphasizing the impact of the lack of dental care. The deficiency was identified through observations, record reviews, and interviews with the resident and staff.
Failure to Communicate Resident Allergens and Preferences
Penalty
Summary
The facility failed to ensure that resident allergens and food preferences were properly communicated to the dietary staff, affecting two of the thirteen sampled residents. The facility's policy on food allergies and intolerances, revised in 2009, mandates that residents with food allergies and intolerances be identified upon admission to prevent exposure to allergens. Additionally, the policy on resident food preferences, revised in 2007, requires nursing staff to document residents' likes, dislikes, and special dietary instructions in their clinical records. However, these policies were not effectively implemented for Resident #6 and Resident #31. Resident #6 had expressed a preference not to be served asparagus or broccoli during a Resident Council Meeting, but this preference was not documented in their medical record or diet card. Similarly, Resident #31 had a known allergy to mushrooms, which was acknowledged by a dietary staff member, yet this allergy was not recorded on their diet card. The failure to document and communicate these dietary needs could lead to residents experiencing food intolerances or allergic reactions.
Failure to Ensure Bathing Safety
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident during a bathing session. The incident involved a certified nurse aide (CNA) who used a hair dryer while the resident was still in a tub full of water. The resident expressed concern about the safety of using the hair dryer in such conditions, but the CNA proceeded to dry one side of the resident's hair while they were still in the tub and completed the task after the resident exited the tub. This action placed the resident at risk for serious injury due to the potential hazard of using an electronic device near water. The incident was reported by the resident's family member to the Director of Nursing (DON), prompting an investigation. The facility's policy, revised in June 2024, explicitly stated that electronic devices should not be near the bathtub or shower while a resident is bathing or near standing water. The CNA's actions were in direct violation of this policy, highlighting a failure to adhere to established safety practices during resident care.
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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