Bethel Lutheran Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Williston, North Dakota.
- Location
- 1515 2nd Ave West, Williston, North Dakota 58801
- CMS Provider Number
- 355070
- Inspections on file
- 20
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Bethel Lutheran Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a breast lump had ongoing right breast hardness and later worsening scabbed, reddened, and draining changes, but the record lacked evidence of provider assessment or a mammogram order before the resident was sent to the ER and hospitalized for breast infection and possible cancer. Another resident with dysphagia was ordered nectar thick liquids via straw, but staff offered liquids in a glass and later a sipper cup instead, and the resident immediately coughed after each attempt; the care plan still listed sipper cups with spouts.
Failure to maintain resident dignity and provide timely assistance: staff used residents’ clothing protectors and a spoon to wipe food from residents’ mouths during meals instead of a napkin, left one resident calling out for help in the room for an extended period, and did not adequately supervise or assist two residents who needed meal cueing, encouragement, or help. One resident with stroke-related weakness, mild cognitive impairment, and dysphagia struggled to self-feed with adaptive utensils out of reach, while another resident with dysphagia was left with a barely eaten meal and repeated requests for help.
Medication administration errors exceeded the allowed rate when an LPN made four errors during 27 observed med passes, resulting in a 14% error rate. Errors included crushing finasteride ordered not to be crushed, giving levothyroxine with food instead of on an empty stomach, and priming insulin pens at the wrong angle for two residents. Facility policy and staff interview confirmed the correct administration requirements.
Staff failed to follow infection control practices during resident care and medication tasks. A CNA did not use gown and gloves as required during toileting and catheter-related care, another resident with MRSA and multiple wounds did not have EBP in place during brief care and transfer, and a CNA touched equipment and other items without proper hand hygiene or glove changes during EBP care. A nurse also moved from dirty to clean wound care without changing gloves or performing hand hygiene, gave oral meds and eye drops without changing gloves, and prepared insulin pens without disinfecting the rubber stoppers.
Failure to protect a resident from physical abuse resulted in a bruise to the resident's arm after another resident yanked the resident's wrist and slapped the resident's face. The injured resident had dementia with psychotic disturbance, anxiety, depression, restlessness, and agitation, and was unable to explain what happened. The other resident had dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations; the care plan noted a tendency for physical and verbal behaviors but did not address aggression toward other residents, and staff confirmed the incident was not thoroughly reported or investigated.
Manual restraint used during resident care. A resident with dementia, agitation, and behavioral symptoms was documented as becoming violent during brief changes, and multiple staff members held the resident's arms, hands, and legs while providing care. The record did not show attempts to reapproach the resident or minimize the number of staff present, and an admin nurse stated staff should not physically restrain residents.
Failure to report alleged abuse incidents: The facility did not report 3 suspected physical or sexual abuse events to the SSA as required by policy. One resident with dementia, agitation, and psychotic disorder had episodes of violent behavior during care, another resident was reportedly yanked and slapped by a peer, and a third resident with dementia, anxiety, and hallucinations was reportedly grabbed on the breast by a male resident. Two administrative staff confirmed the incidents were not reported to the SSA.
Failure to investigate allegations of abuse: The facility did not thoroughly investigate multiple abuse-related incidents involving residents with dementia, agitation, and other behavioral symptoms. Records showed staff physically held a resident during violent episodes, one resident was reportedly yanked and slapped by another resident, and another resident was grabbed by the breast by a male resident. Two administrative staff confirmed the incidents were not investigated.
Failure to notify the State LTC Ombudsman of a resident discharge. A resident’s record showed the resident was to discharge home after therapy was complete, but there was no evidence the facility sent the required written discharge notice to the State Ombudsman. An administrative staff member confirmed the missing notification in the record.
Care plan not updated after repeated behavioral incidents. A resident with dementia, agitation, depression, irritability/anger, and psychotic disorder had a care plan noting physical and verbal behaviors and the need to remove the resident from stressful situations, but the plan was not revised after episodes of punching and kicking during care and an incident in which the resident yanked another resident’s wrist and slapped the resident’s face.
Improper Sit-to-Stand Lift Transfer: Staff failed to use a sit-to-stand lift according to manufacturer instructions during transfers of a resident with dementia, disc degeneration, and pain. During two observed bed-to-toilet transfers, two CNAs raised the lift while the resident did not bear weight and remained seated in the harness, with the straps pulling into the axillae and raising the shoulders until the resident was lowered onto the toilet. The care plan called for a PAL lift with assist of 2, and admin staff confirmed residents should bear weight when using the lift.
A resident receiving hemodialysis with a right forearm AV fistula had incomplete dialysis communication forms and no documented post-dialysis or fistula assessments across all dialysis visits reviewed. The resident had an order for twice-daily fistula checks, but nursing documentation and dialysis center reports were missing for multiple visits, and admin staff confirmed the gaps in communication and assessment.
A resident’s Novolog sliding scale insulin was prepared by an LPN, but the insulin pen label did not match the provider’s order. The order specified different dose ranges and unit amounts than those printed on the pen label, and admin staff confirmed the discrepancy.
Failure to notify the physician and resident representative of a significant breast tissue change. A resident with a right breast lump developed a hardened area around the areola, scabbing, erythema, discharge, and worsening wound findings, later requiring ER transfer for evaluation. The record showed the guardian was not informed about the lump or the provider’s recommendation for no further treatment, and the provider was not notified when the area showed signs of infection and bacitracin was applied.
The facility failed to update care plans for four residents, affecting the staff's ability to ensure continuity of care. A resident with knee pain, another with dietary changes due to dysphagia, a diabetic resident on insulin, and a resident with insomnia on Ambien had care plans that did not reflect their current medical orders and conditions.
The facility failed to document and communicate the code status of two residents in the EHR, as required by their POLST forms. One resident's form indicated Full Code, and another's indicated DNR/Limited interventions, but neither had a corresponding physician's order or visible code status in the EHR. Staff interviews confirmed these deficiencies, highlighting a lack of accessible information for direct care staff.
Failure to Follow Up on Breast Lump and Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for a resident with an identified breast lump. The resident’s record showed a breast lump was identified on 10/19/24, and the facility notified the provider on 10/21/24 after the resident agreed to a mammogram. From October 2024 through June 2025, nursing notes continued to document a hard lump on the right breast, but the record lacked evidence that the provider assessed the lump or ordered a mammogram. Later progress notes documented worsening findings of the right breast area, including a scab below the right areola, hardness around the areola, minimal discharge, erythema, increased size, purulent exudate, and a larger reddened and hardened area with tenderness. On 08/06/25, the resident was sent to the ER for evaluation after no improvement in the right breast region. The facility later documented that the resident was admitted to the hospital for infection and possible breast cancer, received IV antibiotics for breast infection, and that a CT scan showed the underlying breast tissue was cancerous. The facility also failed to ensure safe oral intake for a resident with dysphagia who required nectar thick liquids via straw. The resident had diagnoses including cerebrovascular disease, dementia, oropharyngeal dysphagia, and reflux disease, and the speech therapy evaluation identified coughing with thin liquids and ordered a mechanically altered diet with nectar thick liquids via straw sip. The care plan still included sipper cups with spouts, and observations showed staff offering nectar thick liquids in a glass and later in a sipper cup rather than via a straw; each time the resident immediately coughed. Staff also observed that water in the room had not been thickened before it was offered.
Failure to Maintain Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained and respected resident dignity during meals for two sampled residents and two supplemental residents. During dining observations, a CNA fed two residents and used their clothing protectors to wipe excess food from the corners of their mouths, and a nurse used a small coated spoon to remove excess food from one resident’s mouth. On another meal observation, a CNA again used a resident’s clothing protector to wipe food from the resident’s mouth, and the nurse repeated the use of a small coated spoon to remove food from the resident’s mouth. Administrative staff confirmed staff should use a napkin to remove excess food from a resident’s face. The facility also failed to respond in a timely manner to a resident who requested assistance in the room. The resident’s care plan stated the resident needed prompt response to all requests for assistance, could make self understood, and should be encouraged to use the call bell. During observation, the resident’s room door was closed and the resident repeatedly hollered for staff assistance for 37 minutes until the surveyor summoned help. In addition, two residents who required meal supervision, cueing, encouragement, and/or assistance were observed at lunch with inadequate staff support: one resident with hemiplegia, hemiparesis, mild cognitive impairment, dysphagia, and a history of stroke had adaptive silverware out of reach and was left to attempt self-feeding, spilling juice and dropping food into the lap, while another resident with dysphagia was observed drinking from a coffee cup, repeatedly saying, 'Take this,' with the meal barely eaten and no effective cueing or assistance provided.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent for 3 of 6 residents observed during medication administration. During observation of 27 medications administered by nurse #7, four medication errors occurred, resulting in a 14 percent error rate. The report states that failure to follow physician's orders and/or pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. For Resident #12, the medical record showed orders for finasteride 5 mg with directions not to crush or split, and levothyroxine 50 mcg. During observation, nurse #7 crushed the finasteride and placed it, along with the levothyroxine and other medications, in strawberry ice cream for administration. For Residents #3 and #77, nurse #7 primed their insulin pens at a 45-degree angle. Facility policy and reference information reviewed by surveyors stated that finasteride should not be crushed, levothyroxine should be given on an empty stomach, and insulin pens should be primed with the needle pointing upward at a 90-degree angle. Administrative staff confirmed these administration expectations during interview.
Infection Control Failures During Toileting, Wound Care, and Medication Administration
Penalty
Summary
The facility failed to follow infection control and prevention standards during toileting care, wound care, and medication preparation and administration for multiple residents. Facility policies reviewed by surveyors stated that enhanced barrier precautions (EBP) were required for residents with indwelling devices or wounds, that staff should wear gowns and gloves for high-contact care activities such as changing briefs, assisting with toileting, and device care, and that hand hygiene was required before and after glove use, before preparing medications, and when moving from a contaminated body site to a clean body site. The insulin pen policy also required wiping the rubber seal with alcohol before attaching the needle. For a resident with an indwelling Foley catheter and an EBP care plan, two CNAs transferred the resident to the toilet and emptied urine from the catheter bag into a urinal, but one CNA did not wear a gown and gloves while emptying the urinal into the toilet, did not wear a gown when changing the resident’s shirt, and touched the resident’s water mug without removing gloves and performing hand hygiene. For another resident with a history of MRSA, a left heel pressure ulcer, and two diabetic ulcers with daily dressing orders, surveyors observed no EBP in place, and two CNAs completed brief care and a mechanical-lift transfer without wearing gowns. For a third resident with an indwelling catheter and EBP, a CNA removed soiled gloves during bowel movement and perineal care, then touched equipment and other items in the room without hand hygiene or clean gloves, and later handled the resident’s clothing, shoes, lift equipment, trash, and bedding with similar breaks in glove use and hand hygiene. During wound care for a resident with a sacral pressure ulcer and dressing orders, a nurse removed soiled dressings and then cleansed and treated the wound without removing the soiled gloves, performing hand hygiene, or applying new gloves when moving from dirty to clean tasks. During medication pass, the same nurse administered oral medications and then eye drops without changing gloves or performing hand hygiene, and prepared insulin pens for two residents without disinfecting the rubber stoppers before attaching needles. Administrative staff stated they expected staff to change gloves between oral medications and eye drops and to disinfect insulin pen tips before attaching sterile needles.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure a resident remained free from abuse when Resident #48 sustained a bruise to the left inner forearm after an incident involving Resident #9. Resident #48 had diagnoses including anxiety, dementia with psychotic disturbance, depression, restlessness, and agitation. Nursing documentation stated that on 12/04/25, staff heard a scream from the unit lounge and observed Resident #9 yank Resident #48's left wrist and slap the left side of the face twice. The resident's left cheek was noted to be reddish in color, and cold compresses were applied to the cheek and left dorsal hand. The following day, nursing staff documented a 1.5 cm by 1.5 cm bruise to Resident #48's left inner forearm. Resident #48 was oriented to self only and unable to verbalize what happened. Resident #9 had diagnoses including dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations, and the current care plan noted a potential for physical and verbal behaviors and that the resident could be easily started and frustrated when too many people were around. The care plan did not address the resident's physically aggressive behaviors toward other residents, and an administrative staff member confirmed the facility failed to report and thoroughly investigate the incident between the two residents.
Manual restraint used during resident care
Penalty
Summary
The facility failed to ensure a resident remained free from restraints when staff used a manual method of restraining Resident #9 during care. Resident #9 had diagnoses including irritability, anger, and dementia with agitation and psychotic disturbances, and the care plan noted the resident had a potential to demonstrate physical and verbal behaviors, could refuse care, could become frustrated when too many people were around, and needed reapproaching. Review of nursing notes showed that during two separate brief-change episodes, the resident became violent, throwing punches and kicking. In one incident, another RN and two CNAs assisted while one staff member held the resident's hands and another held the resident's legs while two other staff cleaned the resident. In the other incident, the writer held the resident's arms, one CNA held the resident's legs, and another CNA washed the resident. The record did not document attempts to reapproach the resident or to minimize the number of staff in the room during these incidents. An administrative nurse stated staff should not physically restrain residents.
Failure to Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report incidents of suspected abuse to the State Survey Agency for 3 of 3 sampled residents with allegations of physical or sexual abuse. The facility policy titled, Abuse, Neglect and Exploitation, dated February 2026, stated that alleged violations must be reported to the state agency, adult protective services, and other required agencies within specified timeframes, immediately but not later than 2 hours after the allegation is made if the events involved abuse. Resident #9 had diagnoses including dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations. Nursing notes documented episodes on 8/9/25 and 8/18/25 in which the resident became violent during brief changes, throwing punches and kicking staff, requiring multiple staff members to hold the resident's hands and legs while care was provided. Resident #48 had diagnoses including anxiety, dementia with psychotic disturbance, depression, restlessness, and agitation; a nurse's note stated that CNA reported Resident #9 yanked Resident #48's left wrist and slapped the left side of the face twice, with redness noted on the left cheek. Resident #42 had diagnoses including dementia, anxiety, restlessness, agitation, and hallucinations; a nurse's note stated that a male resident grabbed her breast after she touched his shoulder. During an interview on 04/16/26, two administrative staff members confirmed the facility failed to report the incidents to the SSA.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate alleged abuse involving 3 sampled residents. Review of the facility policy titled, Abuse, Neglect and Exploitation, dated February 2026, stated that an immediate investigation is warranted when suspicion or reports of abuse occur and that the investigation should analyze why the abuse occurred and what changes are needed to prevent further occurrences. During survey review and staff interview, two administrative staff members confirmed the facility failed to investigate the incidents identified in the record. Resident #9 had diagnoses including dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations, and the care plan noted the resident could demonstrate physical and verbal behaviors, was easily started, and could become frustrated when too many people were around. Nurse's notes documented two episodes in which staff responded to the resident becoming violent during brief changes, with staff holding the resident's arms and legs while other staff cleaned the resident. Resident #48 had diagnoses including anxiety, dementia with psychotic disturbance, depression, restlessness, and agitation; a nurse's note documented an incident in which a CNA reported that Resident #9 yanked Resident #48's left wrist and slapped the left side of the face twice, with redness noted on the left cheek. Resident #42 had diagnoses including dementia, anxiety, restlessness, agitation, and hallucinations; a nurse's note documented that while the resident was being taken back to her room, a male resident grabbed her breast after she touched his shoulder. The facility did not investigate the potential abuse involving Resident #9, the resident-to-resident abuse involving Resident #48, or the potential resident-to-resident abuse involving Resident #42.
Failure to Notify State Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide the State Long Term Care Ombudsman with a written notice of discharge for Resident #81, a closed record reviewed for facility discharge. The medical record included a progress note dated 02/12/26 at 2:17 p.m. stating that the resident was seen for rounds and would be discharging home on 2/18/26 because therapy was complete, but the record did not contain evidence that the facility notified the State Ombudsman of the discharge. During an interview on 04/14/2026 at 3:35 p.m., an administrative staff member confirmed that Resident #81's medical record lacked the required notification to the State Ombudsman.
Care Plan Not Updated After Behavioral Incidents
Penalty
Summary
The facility failed to review and revise the care plan for one resident to reflect current status after documented behavioral incidents. The resident had diagnoses including dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations. The current care plan stated that the resident had the potential to demonstrate physical and verbal behaviors, was easily started, became frustrated when too many people were around, and should be removed from stressful situations. Review of the resident’s nurse’s notes showed two episodes in which the resident became violent during care: on one occasion the resident started throwing punches and kicking during a brief change, and on another occasion the resident again became violent, throwing punches and kicking while staff attempted to provide care. A separate incident involving another resident documented that the resident yanked the other resident’s left wrist and slapped the left side of the face. The facility did not update the resident’s care plan after these incidents, and two administrative staff members confirmed during interview that the care plan had not been revised.
Improper Sit-to-Stand Lift Transfer
Penalty
Summary
The facility failed to ensure staff used a mechanical lift appropriately for one sampled resident during sit-to-stand lift transfers. The facility policy titled Safe Resident Handling/Transfers stated that all residents require safe handling when transferred to prevent or minimize injury and that staff will perform mechanical lifts/transfers according to the manufacturer's instructions. The manufacturer's instructions for the Easy Way sit-to-stand lift stated that the patient's arms should be raised on the outside of the harness, hands placed on the padded handles, and the safety strap tightened as the patient is being raised, with lifting stopped when the patient is in a standing position. Resident #48 had diagnoses including dementia, disc degeneration of the cervical, lumbar, and thoracic regions, and extremity pain. The care plan directed use of a PAL sit-to-stand lift with assist of 2 and noted a history of chronic pain, fractures, arthritis, joint pain, joint stiffness, and swelling. During two observed transfers from bed to toilet, two CNAs raised the lift while the resident failed to bear weight, remained seated, and hung from the harness; the harness straps pulled into the resident's axillae, rolled or pinched the skin above the sling strap, bunched the shirt sleeves, and raised the resident's shoulders until the CNAs lowered her onto the toilet. Administrative staff later confirmed staff should ensure residents can bear weight when using a sit-to-stand lift.
Incomplete Dialysis Communication and Missing Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for Resident #63, who was receiving hemodialysis three times per week and had a right forearm AV fistula. The resident had a physician order to assess the fistula for appearance, bruit, and thrill twice daily. Observation showed the fistula in the right forearm, and the resident confirmed the dialysis schedule of Mondays, Wednesdays, and Fridays. Review of the resident’s dialysis communication forms from 03/13/26 through 04/13/26 showed that 5 of 12 forms did not include the dialysis center’s pre- and/or post-dialysis information. Review of the TARs and nurses’ notes for the same period showed no documentation of post-dialysis or fistula site assessments for all 12 dialysis visits. During interview, two administrative staff members confirmed nursing staff did not ensure the dialysis center completed the communication forms or call the center to obtain a report on the resident’s status, and they also confirmed nursing staff failed to complete and document post-dialysis/fistula assessments after each return to the facility.
Insulin Pen Label Did Not Match Provider Order
Penalty
Summary
The facility failed to ensure that medication labels matched provider orders for one resident observed for insulin administration. A review of the resident’s medical record showed a physician’s order for Novolog insulin sliding scale in addition to scheduled insulin before meals and at bedtime, with specific additional doses ordered based on blood sugar readings: 150 - 199 for 1 unit, 200 - 299 for 3 units, 300 - 399 for 5 units, 400 - 500 for 7 units, and greater than 500 to call the provider. During observation, a nurse prepared the resident’s Novolog sliding scale insulin, but the label on the insulin pen listed different dose ranges and amounts than the provider’s order, including 0 - 199 for 0 units, 200 - 299 for 2 units, 300 - 399 for 4 units, and 400 - 500 for 6 units. Administrative staff later confirmed that the insulin pen label and the provider’s orders did not match.
Failure to Notify Physician and Representative of Breast Tissue Change
Penalty
Summary
The facility failed to notify the resident’s physician or representative of a change in condition for one closed record involving a resident with a right breast lump and later breast tissue changes. The facility policy titled "Change in a Resident's Condition or Status" stated that the Neighborhood Nurse Manager or designee, or Social Worker, would notify the resident’s next of kin or representative when there was a significant change in physical, mental, or psychosocial status or a need to alter treatment significantly. The resident’s record showed a right breast lump and later progress notes documenting a hardened area around the right areola, a scab below the right areola, erythema, minimal discharge, and worsening wound characteristics with increased size and purulent exudate. The breast area later measured 14 cm by 14 cm with redness, hardness, and a 5 cm by 4 cm scabbed/crusty area, and the resident was sent to the ER for evaluation. The record also showed that one guardian was informed of the hospital admission after the resident was sent out, and an administrative staff member confirmed the facility did not notify the guardian about the breast lump or the provider’s recommendation for no further treatment, and did not notify the provider when the breast tissue showed signs of infection and bacitracin was applied.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of four residents, which limited the staff's ability to communicate needs and ensure continuity of care. Resident #50 reported knee pain, and although there was a physician's order for Biofreeze gel to be applied twice daily, the care plan did not address this condition. Resident #55 had changes in dietary orders due to moderate-severe pharyngeal-esophageal dysphagia, including a pureed texture diet and nutritional supplements, but these changes were not reflected in the care plan. Resident #63, diagnosed with diabetes, had a physician's order for insulin at bedtime, yet the care plan did not include information on insulin use or the signs and symptoms of hypoglycemia or hyperglycemia. Additionally, Resident #81, diagnosed with insomnia, was prescribed Ambien at bedtime, but the care plan failed to address the resident's insomnia and the use of hypnotic medication. An administrative nurse confirmed that care plans are supposed to be reviewed and updated with the MDS and any daily care changes, but this was not done for these residents.
Failure to Document and Communicate Residents' Code Status
Penalty
Summary
The facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment were upheld for two residents reviewed for advanced directives. Specifically, the facility did not accurately document or communicate the code status of these residents in the electronic health record (EHR). For one resident, the POLST form indicated a Full Code status, but there was no corresponding physician's order or visible code status in the EHR accessible to direct care staff. Similarly, another resident's POLST form indicated a DNR/Limited interventions status, yet the EHR also lacked a physician's order and did not display the code status in a manner accessible to staff. Interviews with facility staff confirmed these deficiencies. A nurse indicated that she would typically check the resident profile in the EHR for code status, but the necessary information was not present. An administrative nurse acknowledged the absence of a physician's order in the EHR, which would trigger the display of the code status in the resident's profile. This lack of documentation and communication could potentially lead to the provision of unwanted or inappropriate life-sustaining treatment.
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A resident with dementia, restlessness, agitation, and a documented history of entering others’ rooms, rummaging, and exhibiting verbal and physical behaviors was involved in multiple abusive encounters with other residents. In separate incidents, this resident hit another resident in a TV lounge after handling that resident’s bag, punched a resident on the chin/cheek while following behind with a walker, grabbed another resident’s arm near the TV leading to mutual hitting and a fall onto a recliner occupied by a third resident, kicked a resident while being escorted to dinner, and lifted a resident’s chair cushion while searching for a wallet, leading to a profane verbal exchange. Several of the involved residents had impaired cognition, while others had intact cognition but histories of mood and behavioral issues. Staff interviews showed limited description of immediate protective actions when witnessing resident-to-resident aggression, and an administrator noted that the aggressive resident had not been evaluated by psychiatry for an extended period. The facility failed to prevent repeated verbal and physical abuse among residents, resulting in retaliatory abuse toward the aggressive resident.
Two residents did not receive care that maintained their dignity during grooming and personal hygiene. One resident had noticeable facial hair and reported preferring to be shaved with an electric razor, but stated that only a straight razor was available, despite facility policy and administrative statements that grooming should follow resident preference and that shaving materials are provided. Another resident was transferred to bed by a nurse and a CNA, given perineal care, and placed in a clean brief, but staff left the resident’s pants down and simply covered the resident with a blanket, contrary to administrative expectations that pants be pulled up or removed in bed according to resident preference.
A resident with Parkinson’s disease, muscle weakness, unsteadiness on feet, and gait/mobility abnormalities had a care plan requiring a stand-pivot transfer with two staff and a gait belt. During an observed toileting transfer, two CNAs assisted the resident, who showed visible shakiness and an unsteady gait, but one CNA placed her hands around the resident’s ribcage to move the resident back to the wheelchair instead of using a gait belt as required. The CNA later acknowledged not using a gait belt, and administrative staff confirmed their expectation that gait belts be used during transfers per the care plan.
Staff failed to follow infection prevention and control policies when handling reusable equipment and soiled linens for two residents, including one on enhanced barrier precautions (EBP). A CNA removed a full body mechanical lift from a resident’s room without disinfecting it, despite facility expectations for cleaning after each use. In a separate incident, CNAs entered the room of a resident on EBP wearing only gloves initially, and one CNA placed soiled linens on the floor instead of directly into a bag, even after donning a gown. An RN later confirmed that staff were expected to disinfect lifts after every use, avoid placing soiled linen on the floor, and wear gowns upon entering EBP rooms.
The facility failed to prevent resident-to-resident physical abuse when a cognitively impaired resident with dementia-related behavioral issues, already care planned for aggressive mood fluctuations and a history of physical contact, grabbed and forcefully squeezed another resident’s arm in a hallway and, in a separate episode, yelled and struck another cognitively impaired resident in the face multiple times while they were seated together. In both incidents, the affected residents, who had dementia and other psychiatric diagnoses, reported or were documented as having been physically assaulted, though no injuries were ultimately noted, demonstrating that residents were not kept free from abuse by another resident as required by facility policy.
The facility failed to investigate two separate resident-on-resident altercations involving a cognitively impaired resident with dementia, anxiety, and a care plan noting aggressive mood fluctuations and prior physical contact with others. In the first incident, this resident grabbed and forcefully squeezed another resident’s arm in a hallway after being tapped on the shoulder, but the facility did not complete the interviews and root cause analysis required by its abuse policy. In the second incident, the same resident began yelling, swinging, and striking another resident in the face multiple times while they were sitting and talking; although the assaulted resident had no noted injuries and the aggressor was moved to a quiet area, there is no evidence of a thorough abuse investigation or evaluation of interventions after the initial event.
A resident with Parkinson’s disease and Alzheimer’s disease, who was non-verbal, non-ambulatory, and unable to self-transfer, had a care plan requiring substantial assistance by two staff and use of a sit-to-stand lift for transfers after 5 p.m. Facility policy also required use of mechanical lifts as a safer alternative and mandated two staff for mechanical lift transfers. Despite these requirements, a CNA did not follow the care plan during a transfer, and the resident was later found with a head lump, facial and hand lacerations, and blood on the floor. An investigation concluded the injuries likely occurred during or shortly after this improper transfer, in which the required lift and two-person assistance were not used.
A resident with a breast lump had ongoing right breast hardness and later worsening scabbed, reddened, and draining changes, but the record lacked evidence of provider assessment or a mammogram order before the resident was sent to the ER and hospitalized for breast infection and possible cancer. Another resident with dysphagia was ordered nectar thick liquids via straw, but staff offered liquids in a glass and later a sipper cup instead, and the resident immediately coughed after each attempt; the care plan still listed sipper cups with spouts.
Failure to maintain resident dignity and provide timely assistance: staff used residents’ clothing protectors and a spoon to wipe food from residents’ mouths during meals instead of a napkin, left one resident calling out for help in the room for an extended period, and did not adequately supervise or assist two residents who needed meal cueing, encouragement, or help. One resident with stroke-related weakness, mild cognitive impairment, and dysphagia struggled to self-feed with adaptive utensils out of reach, while another resident with dysphagia was left with a barely eaten meal and repeated requests for help.
Medication administration errors exceeded the allowed rate when an LPN made four errors during 27 observed med passes, resulting in a 14% error rate. Errors included crushing finasteride ordered not to be crushed, giving levothyroxine with food instead of on an empty stomach, and priming insulin pens at the wrong angle for two residents. Facility policy and staff interview confirmed the correct administration requirements.
Failure to Prevent Repeated Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from verbal and physical abuse by another resident with known behavioral issues. Facility policies on resident-to-resident altercations and abuse/neglect defined verbally aggressive behaviors such as screaming and cursing, and physically aggressive behaviors such as hitting, kicking, grabbing, pushing, and rummaging through others’ property, and affirmed residents’ right to be free from verbal, physical, and mental abuse. Resident #1 had documented diagnoses including dementia, restlessness, and agitation, with a care plan noting a history of entering other residents’ rooms, rummaging, and exhibiting verbal and physical behaviors. Despite this, Resident #1 was involved in multiple altercations with other residents over a short period. In one incident with Resident #3, video and investigation documentation showed Resident #3 sitting in a recliner in a common TV area while Resident #1 was near other recliners. Resident #3 told Resident #1 to leave electrical cords alone, then got up and approached Resident #1. Resident #1 began to handle Resident #3’s bag on the recliner, after which Resident #3 hit Resident #1 on the left side of the head, and Resident #1 hit Resident #3 on the left arm. Resident #3 had a history of depression, anxiety, mental disorder, mild cognitive disorder, and prior verbal and physical behaviors, with an MDS indicating intact cognition. In another incident with Resident #4, video review and notes showed Resident #4 ambulating with a walker past the nurse’s station into the TV area, followed closely by Resident #1. Resident #1 was seen standing directly behind Resident #4, appearing to make a comment; Resident #4 swatted at Resident #1, and Resident #1 then struck Resident #4 on the left chin/cheek area. A progress note documented that Resident #1 punched Resident #4 when Resident #4 did not respond to Resident #1’s attempt to engage in conversation. Additional altercations involved Resident #2, #5, and #6. In the incident with Resident #2, video review showed Resident #1 standing in front of the TV fidgeting with the control box, then later walking over to Resident #2 and grabbing her arm as if to guide her away from the TV. Resident #2 responded by hitting Resident #1’s left arm, and Resident #1 hit her back on the right arm; both then grabbed each other, fell onto a recliner occupied by another resident, and staff intervened. Resident #2’s MDS indicated severely impaired cognition, and she sustained transient red marks on her head and upper inner arm. In another event, the activity director was walking residents to dinner when Resident #1 kicked Resident #5, who was walking in front, and then chuckled; Resident #5, who also had severely impaired cognition, recalled being kicked and stated the other resident was “not 100 percent.” In a separate episode with Resident #6, staff heard Resident #6 yelling profanities at Resident #1, who was lifting her chair cushion looking for his wallet; Resident #1 raised his voice and called her an explicit name, and Resident #6 prepared to remove her shoe to use toward him before staff intervened. Resident #6, with intact cognition, later stated that Resident #1 wanted to hurt her and that he had hit her friend (Resident #4) for no reason. Staff interviews further illustrated gaps in protecting residents from abuse. One staff member, when asked what she would do if she witnessed a resident hit another resident, stated she would get the RNs and “try to get a hold of someone,” without describing immediate protective interventions. An administrative staff member reported that Resident #1 had not been seen by psychiatry since 2024, despite his documented dementia with psychotic disturbances and ongoing behavioral issues. Across these events, the facility did not prevent repeated verbal and physical altercations initiated or escalated by Resident #1 toward other residents, which led to retaliatory physical and verbal abuse by those residents toward Resident #1.
Failure to Maintain Resident Dignity During Grooming and Personal Care
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents who required assistance with personal hygiene and care. Facility policy on promoting/maintaining resident dignity stated that residents should be groomed and dressed according to their preferences, and the grooming policy specified assisting residents with facial hair care to maintain proper hygiene. During observation, one resident was noted to have noticeable facial hair and, in an interview, stated a preference to have facial hair shaved with an electric razor; the resident reported that the facility only had a straight razor available. An administrative staff member stated that all residents are shaved per their preferences and that shaving materials are provided, which conflicted with the resident’s report. In a separate observation, a nurse and a CNA transferred another resident from a wheelchair to a bed, completed perineal care, applied a clean brief, and then covered the resident with a blanket without pulling up the resident’s pants. Later, an administrative staff member stated that she expected staff to either pull up or remove residents’ pants in bed according to resident preference, indicating that the observed practice did not align with facility expectations or policies regarding resident dignity and grooming.
Failure to Use Gait Belt During Stand-Pivot Transfer
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to follow its Safe Resident Handling/Transfers policy and the resident’s care plan requiring use of a gait belt during transfers. The facility policy stated that residents are to be handled and transferred safely to prevent or minimize risk for injury and that lifting and transferring will be performed according to the resident’s individual plan of care. Resident #2’s medical record showed diagnoses of Parkinson’s disease, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. The resident’s current care plan specified a stand-pivot transfer with two staff assisting and the use of a gait belt. During an observation, two CNAs wheeled Resident #2 to the toilet, where the resident used grab bars to transfer from the wheelchair to the toilet, exhibiting visible shakiness and an unsteady gait. After toileting, one CNA cued the resident to stand, applied a clean brief and pants, then placed her hands around the resident’s ribcage to assist the resident back to the wheelchair instead of using a gait belt as required by the care plan. The CNA later confirmed in an interview that a gait belt was not used during toileting care. In a separate interview, three administrative staff members stated they expected staff to utilize a gait belt during transfers as care planned.
Failure to Follow Infection Control Practices for Equipment Cleaning and EBP
Penalty
Summary
Surveyors identified that staff did not follow the facility’s infection prevention and control policies related to cleaning reusable equipment, handling soiled linen, and implementing enhanced barrier precautions (EBP). The facility’s policies required that reusable equipment be cleaned and disinfected according to current procedures and manufacturer’s instructions after each resident use, and that EBP involve targeted gown and glove use during high-contact resident care activities. During observation, a CNA removed a full body mechanical lift from a resident’s room and failed to disinfect it, while stating that lifts and wheelchairs were cleaned by the night shift, contrary to the facility’s expectation that the lift be disinfected after every use. Surveyors also observed failures in infection control practices for a resident on EBP. Two CNAs entered the resident’s room and initially only applied gloves. One CNA placed soiled linen from the floor into a bag, and after being instructed by a nurse to apply PPE, the CNA then donned a gown but removed soiled linen from the bed and again placed it on the floor. The nurse stated that soiled linens should be placed directly into a bag and not on the floor. An administrative staff member later confirmed that staff were expected to disinfect full body mechanical lifts after every use, avoid placing soiled linen on the floor, and wear gowns when entering rooms requiring EBP precautions.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. Facility policy on abuse, neglect, mistreatment, and misappropriation of resident property, dated 07/07/21, states that all residents have the right to be free from verbal, sexual, and physical abuse and must not be subject to abuse by anyone, including other residents. Despite this policy, one resident with Alzheimer's disease, restlessness and agitation, anxiety disorder, and severely impaired cognition, who had a care plan noting aggressive mood fluctuations related to dementia and anxiety and a history of physical contact with another resident, physically grabbed, pulled, and squeezed another resident's arm in a hallway incident. The resident whose arm was grabbed had non-Alzheimer's dementia, anxiety disorder, depression, and intact cognition, and later reported that the aggressor was strong and that she had to pull her arm away, though she stated she was not hurt. In a separate incident, the same cognitively impaired resident with dementia-related behavioral issues struck another resident multiple times in the face while they were sitting next to each other and talking. The progress note documented that the aggressor began yelling and swinging, hitting the other resident in the face multiple times. The resident who was hit, who had dementia, anxiety, behavior disturbance, psychotic disorder, and severely impaired cognition, reported at the time that the other resident “just started hitting me in the face” and that she moved away, and no injuries or pain were noted on assessment. Both involved residents in this second incident were described as confused and unable to be interviewed for the facility’s FRI investigation. The facility’s failure to prevent these two episodes of resident-to-resident physical abuse, despite known behavioral risks and a care plan addressing aggressive behavior, resulted in residents not remaining free from abuse as required by facility policy.
Failure to Investigate Resident-on-Resident Abuse Incidents
Penalty
Summary
The facility failed to investigate alleged violations of abuse involving two residents who were physically assaulted by another resident with a known history of aggressive mood fluctuations related to dementia and anxiety. Facility policy on Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property required that the nurse begin an investigation immediately, including root cause analysis and interviews with staff, roommates, family, and visitors. An FRI dated 01/25/26 documented an incident in which one resident grabbed, pulled, and squeezed another resident’s arm in the west hallway. The final investigation note only reflected that the resident whose arm was grabbed reported that the aggressor was strong but that her arm was okay, and later described that she had tapped the aggressor on the shoulder to compliment her sweater, after which the aggressor grabbed her arm hard and she had to pull away. There is no documentation in the report of a comprehensive investigation consistent with facility policy. A second FRI dated 02/02/26 documented that the same aggressive resident began yelling, swinging, and hitting another resident in the face multiple times while they were sitting together and talking. The assaulted resident stated that the aggressor “just started hitting me in the face, so I moved away from her” and suggested the aggressor “needs a shot or something.” Assessment at that time showed no injuries and no pain, and the aggressor was moved to a quiet area. Medical records showed the aggressor had Alzheimer’s disease, restlessness and agitation, anxiety disorder, severely impaired cognition, and a care plan noting aggressive mood fluctuations and a history of physical contact with another resident, with an intervention to maintain distance from others when appropriate for safety. The other involved residents had dementia and anxiety disorders, with one having intact cognition and the other severely impaired cognition. Although both incidents were reported to facility administration and the state agency, the facility did not conduct investigations of the altercations in accordance with its policy, nor did it implement and evaluate appropriate interventions following the first incident.
Improper Transfer Without Required Lift and Staff Assistance
Penalty
Summary
The deficiency involves the facility’s failure to properly utilize required assistive devices and staff assistance during a resident transfer, contrary to its Safe Resident Handling/Transfers With Use of Mechanical Lifts policy. The policy required that mechanical lifts be used as a safer alternative when appropriate and that two staff members be utilized when transferring residents with a mechanical lift. The care plan for Resident #1, who had diagnoses including Parkinson’s disease and Alzheimer’s disease and could not self-transfer, specified that the resident required substantial assistance by two staff to move between surfaces from morning until evening, and that after 5 p.m. transfers were to be completed using a sit-to-stand lift with assistance from two staff. On the date of the incident, Resident #1’s progress notes documented that the resident, who was non-verbal and non-ambulatory, was found with a significant lump on the right forehead, a small laceration above the right eye, and a laceration on the right hand, with a small amount of blood on the floor. The resident was unable to undergo a complete neurological assessment due to their condition and was sent to the ER for further evaluation. The facility’s incident investigation concluded that the injuries likely occurred during or shortly after an improper transfer and that a CNA failed to follow the resident’s care plan requiring use of a sit-to-stand lift with two staff, resulting in the unsafe transfer and subsequent injuries.
Failure to Follow Up on Breast Lump and Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for a resident with an identified breast lump. The resident’s record showed a breast lump was identified on 10/19/24, and the facility notified the provider on 10/21/24 after the resident agreed to a mammogram. From October 2024 through June 2025, nursing notes continued to document a hard lump on the right breast, but the record lacked evidence that the provider assessed the lump or ordered a mammogram. Later progress notes documented worsening findings of the right breast area, including a scab below the right areola, hardness around the areola, minimal discharge, erythema, increased size, purulent exudate, and a larger reddened and hardened area with tenderness. On 08/06/25, the resident was sent to the ER for evaluation after no improvement in the right breast region. The facility later documented that the resident was admitted to the hospital for infection and possible breast cancer, received IV antibiotics for breast infection, and that a CT scan showed the underlying breast tissue was cancerous. The facility also failed to ensure safe oral intake for a resident with dysphagia who required nectar thick liquids via straw. The resident had diagnoses including cerebrovascular disease, dementia, oropharyngeal dysphagia, and reflux disease, and the speech therapy evaluation identified coughing with thin liquids and ordered a mechanically altered diet with nectar thick liquids via straw sip. The care plan still included sipper cups with spouts, and observations showed staff offering nectar thick liquids in a glass and later in a sipper cup rather than via a straw; each time the resident immediately coughed. Staff also observed that water in the room had not been thickened before it was offered.
Failure to Maintain Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained and respected resident dignity during meals for two sampled residents and two supplemental residents. During dining observations, a CNA fed two residents and used their clothing protectors to wipe excess food from the corners of their mouths, and a nurse used a small coated spoon to remove excess food from one resident’s mouth. On another meal observation, a CNA again used a resident’s clothing protector to wipe food from the resident’s mouth, and the nurse repeated the use of a small coated spoon to remove food from the resident’s mouth. Administrative staff confirmed staff should use a napkin to remove excess food from a resident’s face. The facility also failed to respond in a timely manner to a resident who requested assistance in the room. The resident’s care plan stated the resident needed prompt response to all requests for assistance, could make self understood, and should be encouraged to use the call bell. During observation, the resident’s room door was closed and the resident repeatedly hollered for staff assistance for 37 minutes until the surveyor summoned help. In addition, two residents who required meal supervision, cueing, encouragement, and/or assistance were observed at lunch with inadequate staff support: one resident with hemiplegia, hemiparesis, mild cognitive impairment, dysphagia, and a history of stroke had adaptive silverware out of reach and was left to attempt self-feeding, spilling juice and dropping food into the lap, while another resident with dysphagia was observed drinking from a coffee cup, repeatedly saying, 'Take this,' with the meal barely eaten and no effective cueing or assistance provided.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent for 3 of 6 residents observed during medication administration. During observation of 27 medications administered by nurse #7, four medication errors occurred, resulting in a 14 percent error rate. The report states that failure to follow physician's orders and/or pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. For Resident #12, the medical record showed orders for finasteride 5 mg with directions not to crush or split, and levothyroxine 50 mcg. During observation, nurse #7 crushed the finasteride and placed it, along with the levothyroxine and other medications, in strawberry ice cream for administration. For Residents #3 and #77, nurse #7 primed their insulin pens at a 45-degree angle. Facility policy and reference information reviewed by surveyors stated that finasteride should not be crushed, levothyroxine should be given on an empty stomach, and insulin pens should be primed with the needle pointing upward at a 90-degree angle. Administrative staff confirmed these administration expectations during interview.
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