Fargo Elim Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fargo, North Dakota.
- Location
- 3534 University Drive S, Fargo, North Dakota 58104
- CMS Provider Number
- 355129
- Inspections on file
- 13
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Fargo Elim Health Care Center during CMS and state inspections, most recent first.
Uncontrolled pain, insulin timing, and wheelchair positioning failures: A resident on hospice with CHF had repeated moaning, restlessness, and grunting while PRN opioid and anxiolytic use was delayed and inconsistent despite hospice staff urging more timely administration. Another resident received rapid-acting insulin well before the meal tray arrived, and a third resident with Parkinson’s disease and dementia was repeatedly observed leaning forward and to one side in a Broda chair with no clear head-positioning intervention in the care plan.
A facility failed to provide dignified, timely assistance with toileting and call lights for multiple residents who needed ADL help. Residents reported night CNA staff were rude, used disrespectful language, delayed or ignored call lights, left residents on the toilet too long, and sometimes refused toileting help, while one resident’s care plan required assist x2 with toileting and regular toileting offers. An observation also showed a CNA speaking in a raised voice during care.
Care plans were not reviewed and revised to match current resident status for several residents. One resident on a diuretic, one with a suprapubic catheter, one with a smoking safety discrepancy, one with a possible elopement/wanderguard issue, and one whose hearing amplifiers were no longer being used all had care plans that did not accurately reflect their current needs or conditions.
The facility failed to accurately code the MDS for two residents. One resident’s quarterly MDS listed PTSD as an active dx even though the resident denied ever having that diagnosis and the record lacked supporting documentation, while another resident’s admission MDS failed to code an ileostomy despite the resident confirming it and the care plan noting the bowel alteration.
Failure to provide timely toileting assistance for two residents. One resident with fecal urgency and a care plan for assist x2 and toileting on arising, after meals, before bed, and PRN reported that night staff ignored call light requests, told him to wait, and left him incontinent; the toileting log showed repeated gaps of 5 to 16 hours. Another resident whose care plan called for toileting in the AM, after meals, HS, and PRN said staff sometimes took a long time or did not come at all, and the toileting record showed repeated gaps of 4 to 24 hours.
Medication labeling was not maintained for a resident's eye drops when an MA removed a bottle from the med cart drawer and administered it even though the bottle only identified a room number and lacked the resident's name and administration instructions. An administrative nurse confirmed that all medications should have labels.
Kitchen Sanitation and Freezer Maintenance Deficiencies: Surveyors observed grease and grime buildup on the ventilation system above the grill and ice/condensation on the walk-in freezer ceiling and on boxes of food stored under the fan. Two dietary supervisors stated the vents and freezer ceiling were not on a regular cleaning schedule and were cleaned as needed.
Infection control and prevention standards were not followed for two residents on EBP for indwelling devices. A nurse caring for a resident with an ileostomy and indwelling catheter removed dressings and reapplied gloves twice without hand hygiene, while also handling a pen from a uniform pocket during care. A CNA caring for a resident with an indwelling catheter drained the catheter bag and then transported the resident in the same soiled gloves without removing them or performing hand hygiene. Facility policy required hand hygiene before and after care, after glove removal, and after handling catheters or urine.
Two male cooks were observed preparing food without wearing beard restraints, contrary to facility policy and FDA Food Code requirements. The facility's policy mandates the use of hairnets, caps, and beard restraints to prevent hair from contacting exposed food and clean equipment. An administrative staff member stated that new hires are told to keep facial hair trimmed, but there was no evidence of enforcement regarding beard restraint use.
Surveyors found that three residents' MDS assessments were inaccurately coded regarding high-risk medications. One resident's antibiotic and another's antidepressant were omitted from their MDS, while a third resident was incorrectly coded as receiving both an antiplatelet and an anticoagulant, despite only receiving an antiplatelet. Administrative staff confirmed these errors during the survey.
Uncontrolled pain, insulin timing, and wheelchair positioning failures
Penalty
Summary
The facility failed to provide necessary care and services to a resident on hospice with uncontrolled pain. Resident #62 had diagnoses including hypertensive heart disease with congestive heart failure and was admitted to hospice. The resident’s care plan directed staff to monitor comfort and medicate per orders, and physician orders included scheduled and PRN hydromorphone and lorazepam. The record and observations showed the resident was moaning, restless, grunting, and fidgeting, with family and hospice staff expressing concern that pain was not being assessed regularly and PRN pain medication was not being given in a timely manner. Facility documentation showed PRN hydromorphone and lorazepam were administered intermittently, with the last PRN hydromorphone given at 1:10 a.m. on 03/12/26 and the last PRN lorazepam given at 5:21 p.m. on 03/11/26. During observation on 03/12/26, the resident was leaning to one side, using accessory muscles to breathe, moaning, grunting, and calling for help until a nurse entered and administered scheduled hydromorphone, lasix, and lorazepam; the resident then appeared comfortable within minutes. Hospice notes documented repeated encouragement to facility staff to use PRN hydromorphone and lorazepam for nonverbal signs of pain and restlessness, and hospice staff stated the facility should use PRN medications more frequently and timely. The facility also failed to follow professional standards during insulin administration for another resident. Resident #27 received Fiasp insulin at 5:00 p.m., but the meal tray was not provided until 6:15 p.m., which was outside the manufacturer’s instruction to inject at the start of a meal or within 20 minutes after starting a meal. The nurse acknowledged the meal was not available at the time of insulin administration and stated a snack or juice was not offered. In addition, the facility failed to ensure proper wheelchair positioning for Resident #58, who had Parkinson’s disease, dementia with behavioral disturbance, osteoarthritis, pain, and restlessness/agitation. Observations showed the resident seated in a Broda chair leaning forward and to the right, while the care plan did not include interventions for proper head positioning and staff described using a blanket for head support that frequently fell out of place.
Failure to Provide Dignified, Timely Assistance With Toileting and Call Lights
Penalty
Summary
The facility failed to provide necessary care in a manner that promotes, maintains, or enhances residents’ quality of life for 16 of 35 sampled residents who required assistance with ADLs. The deficiency centered on failure to assist dependent residents with toileting, delayed or absent responses to call lights, and staff speaking to residents in a manner that was not dignified. The report states that these actions and inactions affected residents’ psychosocial and personal dignity. Resident #67’s record showed a care plan for assist x2 with toileting and toileting offers upon arising, after meals, before bed, and as requested. Resident #67 reported that at night staff did not come when the call light was used, that the call light was turned off at the nurses’ station, and that he had wet and soiled himself because help did not arrive. He also reported that a night CNA told him he had to wait to use the bathroom because it was not his time, then turned off the call light and left. During observation, two CNAs assisted Resident #67 with evening care and toileting, and one CNA told him to lock his wheelchair brakes, then stated, "He can lock it," and later raised her voice and told him, "SIT." Other residents and a visitor described similar concerns with night shift care. Residents reported rude, disrespectful, or rough treatment, call lights not being answered for long periods or not at all, being left on the toilet for extended periods, being told to use a bedpan when toileting was difficult, and staff speaking in another language and laughing during care. One resident reported needing to manage catheter care independently because staff were rude and slow to answer the call light. Another resident’s family member stated staff were not friendly, did not answer the call button at night, and left the resident on the toilet for long periods. An administrative staff member stated the expectation was that residents be treated with respect and dignity, like family.
Care plans not updated to reflect residents’ current status
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of 5 of 20 sampled residents. Facility policy stated that care plans are to be updated with the MDS/care conference schedule and as needed so they remain an accurate reflection of the resident and care needs. Review of the sampled records showed that Resident #5 was receiving spironolactone for chronic combined systolic and diastolic heart failure, and a quarterly MDS identified diuretics as a high-risk medication, but the care plan did not include a problem, goal, or interventions related to diuretic use. Resident #11 had a suprapubic catheter, but the care plan incorrectly referred to an indwelling urethral catheter and did not accurately reflect the resident’s current catheter status. Resident #27’s care plan described the resident as smoking regularly and included multiple smoking-related interventions, but a smoking risk assessment identified the resident as not safe to smoke under any circumstances. Resident #38 had diagnoses including legal blindness and mild cognitive impairment, and an admission MDS identified severe problems with thinking and memory; however, the record lacked documentation of a reported incident in which the resident’s husband brought her to their apartment without alerting staff, and the care plan did not address the possible elopement incident or the wanderguard that was placed in response. Resident #58’s care plan stated that the resident used bilateral amplifiers and kept them at bedside when not in use, but a nurse stated the amplifiers were kept in the top drawer of the nightstand and were no longer utilized per the family’s request, and the care plan was not revised to reflect that change.
MDS Coding Errors for Active Dx and Ileostomy
Penalty
Summary
The facility failed to ensure accurate coding of the MDS for 2 of 34 sampled residents. For Resident #6, a quarterly MDS coded post-traumatic stress disorder (PTSD) as an active diagnosis, but the resident stated he had never been diagnosed with PTSD. The medical record did not contain documentation of a PTSD diagnosis, behaviors, medical treatments, or nursing monitoring related to PTSD, and an administrative staff member confirmed the MDS was coded incorrectly. For Resident #64, the resident confirmed the presence of an ileostomy during interview, and the care plan stated the resident had an alteration in bowel status related to the ileostomy. However, an admission MDS failed to code the ileostomy in Section H for appliances. An administrative staff member stated it is an expectation that the MDS reflect a resident's current status.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance for two residents who required staff help with bowel and bladder needs. Facility policy stated that nursing assistants should assist with toileting needs per resident request and refer to the care plan for individualized toileting needs. Resident #67 had a diagnosis of fecal urgency and a care plan directing staff to provide assist x2 with toileting, offer toileting upon arising, after meals, before bed, and as requested. During interviews, the resident stated that at night staff did not respond when he turned on the light or call light, that he had wet his pants and had soiled himself because help did not come, and that a CNA told him he would have to wait when he said he needed to urinate. A CNA stated the resident had reported this issue several times and that it had been reported to the nurse. Resident #67's toileting record from February 15, 2026 through March 10, 2026 showed 72 occasions when staff failed to assist with toileting as care planned, with gaps of approximately 5 to 16 hours between assistance. Resident #4 stated that it sometimes took a long time for staff to help with toileting, if they came at all, and a strong bowel movement odor was noted in the room. Resident #4's care plan directed staff to offer toileting in the morning, after every meal, at bedtime, and as requested, but the toileting record from February 15, 2026 through March 10, 2026 showed 94 occasions when staff failed to assist per the care plan, with gaps of approximately 4 to 24 hours between assistance.
Medication Bottle Lacked Resident Label and Administration Instructions
Penalty
Summary
Medication labeling was not maintained in accordance with accepted professional principles for one sampled resident observed receiving eye drops. During observation on 03/11/26 at 1:03 p.m., a medication assistant prepared medications for Resident #46 by removing a bottle of lubricating eye drops from the medication cart drawer and administering it to the resident. The bottle identified a room number but did not have a label with the resident's name or instructions for administration. The report cites professional reference material describing the three checks for safe medication administration, including comparing the medication label against the MAR. During interview on 03/12/26 at 2:55 p.m., an administrative nurse confirmed that all medications should have labels.
Kitchen Sanitation and Freezer Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen areas. During observation of the kitchen, surveyors noted an accumulation of grease and grime on the ventilation system above the grill, as well as an accumulation of ice and condensation on the ceiling above and beside the fan of the walk-in freezer, with ice also present on boxes of food stored under the fan. Review of the facility policy stated that kitchen surfaces not in contact with food shall be cleaned enough to prevent the accumulation of grime. During interviews, two dietary supervisors stated that the vents above the grill and the walk-in freezer ceiling were not on a regular cleaning schedule and were cleaned as needed.
Infection Control and Hand Hygiene Failures During EBP Care
Penalty
Summary
Failure to follow infection control and prevention standards occurred for 2 residents who had enhanced barrier precautions (EBP) in place due to indwelling medical devices. Resident #64’s record showed EBP related to an ileostomy and indwelling catheter. During observation, a nurse entered the room after hand hygiene and donning gown and gloves, removed two buttock dressings, discarded them, cleansed the areas, removed soiled gloves, and then applied clean gloves without performing hand hygiene. The nurse retrieved a pen from a uniform pocket to date the new dressings, applied the dressings and barrier cream, removed gloves again, and again applied new gloves without hand hygiene before continuing care. Resident #86’s record showed a physician’s order and care plan for EBP due to an indwelling catheter. During observation, a CNA entered the room, performed hand hygiene, and applied gloves and a gown. The CNA drained urine from the catheter bag into a clear plastic container and then, while wearing the same gloves, transported the resident from the bathroom to the bedroom via wheelchair. The CNA did not remove the soiled gloves or perform hand hygiene before transporting the resident out of the bathroom. Facility policy reviewed during survey stated that residents with indwelling medical devices require EBP and that hand hygiene is required before and after care, after removing gloves, and after handling catheters or urine.
Failure to Ensure Food Service Staff Wore Required Beard Restraints
Penalty
Summary
The facility failed to ensure that food was prepared in accordance with professional standards for food service sanitation in the kitchen. Observations during multiple kitchen tours and tray line revealed that two male cooks were preparing food without wearing beard restraints, as required by both facility policy and the 2022 FDA Food Code. The facility's policy specifies that hairnets, caps, and beard restraints must be worn to prevent hair from contacting exposed food, clean equipment, utensils, and linens. During an interview, an administrative staff member confirmed that newly hired staff are instructed to keep facial hair trimmed, but there was no mention of enforcement regarding the use of beard restraints.
Inaccurate MDS Coding for High-Risk Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident, a physician's order for cefpodoxime, an antibiotic, was present, but the antibiotic was not coded on the resident's quarterly MDS. For another resident, a physician's order for escitalopram oxalate, an antidepressant, was documented, but the antidepressant was not coded on the quarterly MDS. In both cases, administrative staff confirmed that the medications should have been coded on the respective MDS assessments. Additionally, a third resident had a physician's order for aspirin, an antiplatelet medication, but no anticoagulant was ordered. However, facility staff coded both antiplatelet and anticoagulant medications on the resident's quarterly MDS. This incorrect coding was also confirmed by administrative staff during the survey. These inaccuracies in MDS coding resulted in the residents' assessments not accurately reflecting their current medication regimens.
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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