Dunseith Com Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunseith, North Dakota.
- Location
- 15 1st St Ne, Dunseith, North Dakota 58329
- CMS Provider Number
- 355080
- Inspections on file
- 18
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Dunseith Com Nursing Home during CMS and state inspections, most recent first.
Two residents experienced abuse, including yelling, intimidation, and threats by staff, as well as physical altercations between residents. Staff failed to use proper de-escalation techniques, did not maintain resident dignity, and did not report incidents or injuries promptly to supervisory staff, resulting in unaddressed physical and mental distress.
Staff failed to promptly report an incident where a resident with cognitive impairment and behavioral health diagnoses was subjected to yelling, distress, and improper handling by multiple CNAs during a transfer. The resident was left naked on the bathroom floor, found crying with unexplained scratches, and the full details were not communicated to the charge nurse or reported to authorities within the required timeframe.
A resident with chronic pain and dementia exhibiting agitation experienced multiple episodes of pain and aggressive behavior toward staff and other residents. Despite these documented incidents, the care plan was not updated to address pain management or behavioral interventions, and administrative staff confirmed the need for revisions. The facility also could not provide its care plan policy when requested.
The facility did not ensure that the dietary manager had completed the required certification or education to serve as the director of food and nutrition services, as the manager had not finished the certified dietary manager course and was working under an extension.
The facility did not ensure that its high temperature dishwasher consistently sanitized dishware, as staff only recorded external gauge readings and did not check plate-level temperatures. When a dish thermometer was used, it took multiple cycles to reach the required 160°F, and the facility's own thermometer was not functional, resulting in inadequate monitoring of dish sanitization.
The facility did not ensure its QAA Committee met quarterly as required, missing meetings in two quarters and failing to include the medical director in any meetings, as confirmed by administrative staff and review of meeting minutes.
Staff did not adhere to professional standards during insulin administration, including improper priming of insulin pens and failure to notify a physician about out-of-range blood glucose levels for a resident with diabetes. These actions were not in accordance with facility policy and were confirmed by administrative staff.
A resident's financial power of attorney was not provided with required quarterly financial statements for the resident's personal fund account, as confirmed by both the representative and business office staff. This omission prevented the representative from verifying account transactions and balances.
A nurse did not follow infection control protocols during a wound dressing change for a resident with chronic wounds. Supplies were placed on an unsanitized bedside table without a barrier, and the nurse failed to change gloves or perform hand hygiene between steps, contrary to facility policy. An administrative nurse confirmed the lapse in infection control practices.
The facility failed to provide appropriate dementia care for a resident with dementia, agitation, and insomnia, who exhibited wandering and inappropriate sexual behaviors. The resident frequently intruded into other residents' rooms, causing distress and safety concerns. The facility did not adequately assess or manage these behaviors, nor did they implement effective interventions, compromising the dignity, privacy, and safety of other residents.
The facility failed to ensure food was stored in accordance with professional standards for food service sanitation in the main kitchen. Observations revealed rusty and rough surfaces on food storage racks, a build-up of black debris on the fan grate, and significant ice build-up in the walk-in freezer, including on food items.
The facility failed to follow infection control standards during medication administration and wound care for multiple residents. A nurse did not remove gloves and perform hand hygiene after performing blood sugar checks and administering insulin, and another nurse was observed double gloving while treating a resident's wounds, which is not the facility's practice.
The facility failed to ensure dignity and provide privacy during personal cares for two residents, with staff entering rooms without knocking or announcing themselves. Additionally, a staff nurse left the treatment cart unattended with residents' eMARs visible on multiple occasions, risking unauthorized viewing of resident records.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident. Observations revealed a strong urine odor, sticky floors, dirty wheelchair cushions, and various debris. Interviews with CNAs and an administrative nurse confirmed the need for cleaning attention, and the facility's policy on routine cleaning and disinfection was not followed.
The facility failed to accurately code the MDS for two residents, affecting the accuracy of their assessments and potentially their care plans. One resident's therapeutic diet was not reflected in the MDS, and another resident's significant weight loss was incorrectly coded as being on a physician-prescribed weight-loss regimen.
The facility failed to review and revise care plans for three residents, limiting staff's ability to communicate needs and ensure continuity of care. One resident was at risk for elopement, another had advanced dementia with behavioral issues, and a third was a fall risk with a recent fracture. Despite these conditions, their care plans lacked necessary interventions.
The facility failed to notify the physician of critical changes in a resident's systolic blood pressure and weight, despite specific orders to do so. This failure was confirmed by an administrative nurse and placed the resident at risk for delayed treatment and adverse health events.
The facility failed to provide timely toileting assistance to a resident, as required by their care plan. Observations and records showed that the resident was not assisted every two to three hours, resulting in wet clothing and a strong odor of urine. Staff confirmed the resident should be toileted regularly, but there were 20 instances of non-compliance, with gaps of 7 to 16 hours between assistance.
The facility failed to deposit residents' funds in an interest-bearing account for two residents. A review of a quarterly statement and an interview with business office employees confirmed that the funds were kept in a non-interest-bearing checking account.
Failure to Protect Residents from Abuse and Inadequate Response to Incidents
Penalty
Summary
The facility failed to protect two residents from abuse, including verbal, mental, and physical abuse by staff, as well as resident-to-resident altercations. One resident with anxiety, conduct disorder, depression, and moderate cognitive impairment was subjected to yelling, intimidation, and threats by multiple CNAs during an attempt to assist her with toileting. Staff were observed hollering at the resident, pointing in her face, and insisting she apologize while she was naked and distressed on the bathroom floor. The resident was found crying with fresh scratches on her arm, which staff could not adequately explain. Staff also threatened to withhold snacks as a form of punishment, and failed to report the incident and injuries to the charge nurse in a timely manner. Another resident with dementia and agitation exhibited behaviors that led to two separate resident-to-resident altercations. In one incident, the resident was found holding another resident's arm and struck the other resident in the face with a closed fist. In a separate event, the same resident hit another resident in the mouth during a verbal outburst in the activity room. Both incidents resulted in staff intervention to separate the residents and assess for injuries, though no significant injuries were noted at the time. The facility's policies on abuse, neglect, and exploitation were not followed, as evidenced by staff's failure to prevent and appropriately respond to abusive behaviors, both from staff to resident and resident to resident. Staff did not use appropriate de-escalation techniques, failed to maintain residents' dignity, and did not ensure timely and accurate reporting of abuse or injuries to supervisory staff.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
Facility staff failed to report an incident of abuse involving a resident with anxiety, conduct disorder, moderate cognitive impairment, and delusions within the required timeframe. The incident involved multiple certified nurse aides (CNAs) attempting to get the resident up for supper, during which the resident was distressed, yelling, refusing to cooperate, and ultimately ended up naked on the bathroom floor. A gait belt was applied directly to the resident's bare skin, and staff lifted her with it at least once. Several CNAs were reported to have yelled at the resident, pointed in her face, and insisted she apologize. Another CNA later found the resident crying on the floor with scratches on her left arm, which no staff could explain. The resident was then calmed, cleaned, dressed, and brought to supper. The charge nurse was only informed that the resident had a behavior and that a gait belt was used, but was not told about the yelling, the resident being on the floor naked, the number of staff involved, or any injuries. The full details of the incident were not reported to the charge nurse at the time. The facility reported the incident to the State Survey Agency (SSA) six days after the event, which was not within the required two-hour timeframe. An administrative nurse confirmed that the incident was not reported in a timely manner and acknowledged that it was unacceptable for staff to holler at or threaten residents.
Failure to Update Care Plan for Resident with Pain and Aggression
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain and dementia with agitation, despite multiple documented incidents indicating changes in the resident's condition. The resident's medical record showed 21 instances of pain or requests for pain medication, two occasions of verbal or physical aggression with other residents, and 23 occasions of verbal or physical aggression with staff over a period of approximately two months. The current care plan did not include problems, goals, or interventions addressing the resident's pain or aggressive behaviors. During staff interviews, administrative staff confirmed that the care plan required updates and revisions to reflect the resident's current status. Additionally, the facility was unable to provide a copy of their care plan policy when requested.
Unqualified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the dietary manager had obtained the required qualifications to serve as the director of food and nutrition services. During an interview, the dietary manager stated that she had not completed the certified dietary manager course and had only received an extension to complete it. As a result, the facility did not have a dietary manager who had completed the necessary education for certification as a dietary manager, certified food service manager, or held a national certification for food service management and safety from a recognized certifying body.
Failure to Ensure Adequate Heat Sanitization of Dishware
Penalty
Summary
The facility failed to ensure that the high temperature dishwasher in the main kitchen provided adequate heat sanitization for dishes and utensils. Observations showed that the dishwasher was in use, but the dietary staff only documented temperature readings from the external temperature gauge/dial and did not check dishwash temperatures at the plate level during wash/rinse cycles. When a surveyor's dish thermometer was used, it required up to five wash/rinse cycles before the thermometer registered the required 160 degrees Fahrenheit or above, indicating inconsistent or inadequate sanitization. Additionally, the dietary manager confirmed that staff did not routinely monitor dish temperatures at the plate level and that the facility's dish plate thermometer was not functioning due to a dead battery. The lack of a process or functioning thermometer to verify adequate heat sanitization of dishware contributed to the deficiency, as the facility could not ensure that dishware was being properly sanitized according to professional standards and regulatory requirements.
Failure to Hold Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) Committee met at least quarterly and included all required members, as specified in its own policy. Review of QAA Committee meeting minutes revealed that the committee did not meet during two of the five reviewed quarters, specifically in June and September of 2024. Additionally, the medical director did not attend any of the QAA Committee meetings during the review period. An administrative staff member confirmed that the committee had not met on a quarterly basis and that the medical director's required attendance was not ensured.
Failure to Follow Professional Standards in Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to follow professional standards of practice during insulin administration for four residents observed. Specifically, nurses were seen priming insulin pens incorrectly, either with the needle cap on or while holding the pen downward, contrary to facility policy which requires the needle cap to be off and the pen to be held upright during priming. These observations were confirmed by an administrative nurse who stated the expected procedure was not followed. Additionally, for one resident with Type 2 diabetes mellitus, staff did not notify the physician when blood glucose readings were outside the parameters set by the physician's order. The resident's medical record showed multiple instances of blood sugar levels below 100 mg/dL and above 450 mg/dL, but there was no documentation that the physician was informed as required by facility policy. This was acknowledged by an administrative nurse during interview.
Failure to Provide Quarterly Financial Statements to Resident's Representative
Penalty
Summary
The facility failed to provide the resident's designated financial representative with quarterly financial statements for the resident's personal fund account, as required by facility policy. Review of the policy confirmed that individual financial records must be made available to the resident through quarterly statements. Interviews revealed that the resident's financial power of attorney had not received any such statements, and a business office staff member confirmed that the statements were not sent. This failure prevented the representative from verifying the resident's financial transactions and fund balances.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow the facility's infection prevention and control policy during a wound dressing change for a resident with chronic wounds on the posterior left thigh and bilateral buttocks. The facility's policy required sanitizing the overbed table, placing a barrier before setting up supplies, and performing hand hygiene and glove changes between steps of the dressing change. However, the nurse placed supplies directly on the bedside table without sanitizing it or using a barrier, and did not change gloves or perform hand hygiene between removing the soiled dressing, cleansing the wound, and applying the new dressing. The resident's medical record included physician orders for specific wound care and a care plan addressing impaired skin integrity. During the observed dressing change, the nurse removed soiled dressings, cleansed the wounds, and applied new dressings without following the required infection control steps. An administrative nurse confirmed that proper infection control practices were not followed during this procedure.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for a resident diagnosed with dementia, agitation, and insomnia, who exhibited wandering behaviors and a history of inappropriate sexual behaviors. The resident's medical record indicated multiple incidents of wandering into other residents' rooms, aggressive behaviors, and sexually inappropriate actions towards both residents and staff. Despite these behaviors, the facility did not adequately assess and monitor patterns or trends, nor did they develop an effective behavior management program or person-centered care plan to address these issues. Observations and interviews revealed that the resident frequently wandered into other residents' rooms, sometimes attempting to disrobe or engage in inappropriate behaviors. Staff and other residents reported feeling unsafe and disturbed by these actions. One resident specifically mentioned feeling unsafe and requested a lock on their door due to the frequent intrusions and inappropriate behavior of the resident in question. Staff interviews confirmed the difficulty in redirecting the resident and the negative impact on other residents. The facility's response to the resident's behaviors was insufficient, as they only placed a picture of the resident on his door to help him locate his room more easily. The social service member was unaware of the extent of the resident's sexual behaviors towards others. The facility's failure to implement effective interventions and modify the physical environment compromised the dignity, privacy, and safety of other residents, and did not support the resident in achieving the highest level of functioning.
Failure to Ensure Proper Food Storage Sanitation
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards for food service sanitation in the main kitchen. Observations revealed several deficiencies, including rusty and rough surfaces on food storage racks in the walk-in cooler, which a dietary staff member confirmed were difficult to clean. Additionally, there was a build-up of black debris on the grate of the fan on the ceiling. In the walk-in freezer, there was a significant amount of ice build-up on a pipe, the back north wall, the back east wall, and the ceiling. This ice build-up was also found in an open box of sherbet cups, on packages of coffee, and above a bag of garlic toast and other boxes of food. The facility's policy on sanitation inspections, dated 03/01/24, mandates daily inspections of refrigerators and freezers by food service staff and weekly inspections of all food service areas by the dietary manager. However, the observations made on 04/29/24 and 05/02/24 indicated that these inspections were either not conducted as required or were ineffective in identifying and addressing the sanitation issues. The failure to maintain clean and sanitary conditions in the food storage areas has the potential to result in foodborne illness or adverse effects for patients, visitors, and staff.
Infection Control Deficiencies During Medication Administration and Wound Care
Penalty
Summary
The facility failed to follow standards of infection control for five of fifteen sampled residents during medication administration and resident care. Specifically, a nurse did not remove gloves and perform hand hygiene after performing blood sugar checks and administering insulin to multiple residents. The nurse was observed exiting residents' rooms, disinfecting equipment, placing supplies back into the medication cart, and typing on the computer without changing gloves or performing hand hygiene. This was observed with residents who had chronic conditions and infections, including MRSA and VRE, and were on enhanced barrier precautions. Additionally, another nurse was observed double gloving while treating a resident's wounds, which is not the facility's practice. The nurse did not remove gloves and perform hand hygiene before and after cleansing the wounds and applying medications. This failure to adhere to proper infection control practices has the potential to transmit infections to residents, staff, and visitors. An administrative nurse confirmed that double gloving is not the facility's practice.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure dignity and provide privacy during personal cares for two residents. In one instance, a CNA entered a resident's room without knocking or announcing themselves, which the resident confirmed happens frequently. In another instance, two CNAs were providing care to a resident when a third CNA entered the room without knocking or announcing themselves. These actions violated the facility's policy on promoting and maintaining resident dignity and privacy, which requires staff to knock and announce themselves before entering a resident's room. Additionally, the facility failed to promote privacy and confidentiality of electronic medication administration records (eMAR). A staff nurse left the treatment cart unattended with residents' eMARs visible on four separate occasions. This failure to lock computer screens and ensure the privacy of resident information could result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff. These actions are contrary to professional guidelines that emphasize the importance of maintaining the privacy and confidentiality of client information stored in computers.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for one resident. Observations in the resident's room and bathroom revealed a strong urine odor, a sticky floor with a rust-colored substance around the toilet, and multiple unclean areas including dried food/drink spills on the wall, dirty wheelchair cushions, dust on a shelf, and various debris on the floor. The housekeeping logs and the resident's medical record did not show any evidence that the resident refused housekeeping services. Interviews with two CNAs revealed that the resident did not like the wheelchair cushions from physical therapy and had thrown them on the floor. The CNAs acknowledged that the cushions should have been returned to physical therapy and that the room needed cleaning attention. An administrative nurse also agreed that the room required cleaning. The facility's policy on routine cleaning and disinfection was not followed, leading to the unsanitary conditions observed in the resident's room.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which impacted the accuracy of their assessments and potentially the development of their comprehensive care plans. For Resident #21, the medical record showed a physician's order for a low potassium diet dated 04/27/23. However, the annual MDS did not reflect this therapeutic diet in section K0510D. This discrepancy was acknowledged by the dietary manager during the survey interview on 05/02/24. For Resident #27, the medical record indicated a significant weight loss of 10% over three months, from an admission weight of 125 lbs on 01/25/24 to 111.8 lbs on 04/24/24. Despite this, there were no physician orders for a weight loss regimen. The admission MDS incorrectly coded section K0300 as 'yes,' indicating the resident was on a physician-prescribed weight-loss regimen. This error was confirmed by a nurse manager during an interview on 05/01/24.
Failure to Review and Revise Care Plans
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 #13 was identified as at risk for elopement, with a physician's order for a Wanderguard check three times a day. Despite this, the resident's care plan lacked any mention of wandering or the use of a Wanderguard. Similarly, Resident #23, who had advanced dementia and a history of behavioral issues including wandering and sexually inappropriate behaviors, had no care plan addressing these issues. Observations confirmed the resident's wandering behavior, but the care plan did not reflect any interventions for these behaviors. Resident #179 had a fall resulting in a right elbow fracture prior to admission and was identified as a fall risk with a provider order for maximum fall precautions. Observations showed the resident with a cast, sling, and a chair alarm attached to the wheelchair, yet the care plan lacked any interventions related to fall precautions. An administrative nurse confirmed that the care plan should indicate specific fall precautions for the resident. These deficiencies highlight the facility's failure to update and revise care plans to reflect the current needs and risks of the residents, potentially impacting the quality of care provided.
Failure to Notify Physician of Critical Changes in Resident's Condition
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with specific parameters for weight and blood pressure monitoring. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, chronic bronchitis, hypertension, renal failure, and anemia. Despite physician orders to notify the medical doctor if the resident's systolic blood pressure fell below 100 mmHg or if there was a weight change of 4 pounds or more, the facility did not notify the physician of 12 occurrences of systolic blood pressure below 100 mmHg and four occurrences below 90 mmHg. Additionally, significant weight changes were recorded without notifying the physician, including an 8-pound loss and a 6.4-pound gain within a short period. An administrative nurse confirmed that the staff failed to notify the provider of these changes during an interview. The failure to notify the physician of these critical changes in the resident's condition placed the resident at risk for delayed treatment and adverse health events. The deficiency was identified through a combination of record reviews, professional reference reviews, and staff interviews.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident who required staff assistance with toileting. The care plan for the resident indicated that staff should assist with toileting every two to three hours. However, observations and record reviews revealed that the resident was not assisted as required, resulting in the resident being found with wet clothing and a strong odor of urine on multiple occasions. Specifically, there were 20 instances where staff did not assist the resident with toileting within the specified time frame, with gaps ranging from 7 to 16 hours between assistance. During an interview, two certified nurse aides confirmed that the resident should be toileted every two to three hours. The facility's policy and professional references emphasize the importance of regular toileting to prevent skin breakdown, infection, and other complications. Despite this, the facility failed to adhere to the care plan and policy, leading to the resident experiencing incontinence episodes without timely assistance from staff.
Failure to Deposit Resident Funds in Interest-Bearing Account
Penalty
Summary
The facility failed to deposit residents' funds in an interest-bearing account for two residents. A review of a quarterly statement from the pooled account revealed it was a non-interest-bearing account. During an interview, two business office employees confirmed that they keep petty cash available for residents on weekends and maintain money for each resident in a pooled checking account at the bank. The individual account sheets for the two residents showed that their money was in a non-interest checking account.
Latest citations in North Dakota
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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