Garrison Mem Hosp Nsg Fac
Inspection history, citations, penalties and survey trends for this long-term care facility in Garrison, North Dakota.
- Location
- 407 3rd Ave Se, Garrison, North Dakota 58540
- CMS Provider Number
- 355115
- Inspections on file
- 21
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Garrison Mem Hosp Nsg Fac during CMS and state inspections, most recent first.
Failure to fully inform residents and/or their representatives about psychotropic medication treatment was identified for 5 sampled residents. Record review showed orders for multiple psychotropics, including antianxiety, antidepressant, and antipsychotic medications, but the charts lacked documentation that risks, benefits, alternatives, or consent were discussed and obtained. An administrative staff member confirmed the missing documentation during interview.
Care plans were not kept current for several residents. A resident with opioid and antipsychotic meds, another with diuretics, PRN opioid, and anticoagulation therapy, and others with a catheter, diuretics, antipsychotics, or communication needs had care plans that did not address the resident’s current meds, problems, goals, or interventions. One resident was observed asleep at a dining room table and staff reported he preferred to stay there, but this was not reflected in the care plan.
Dishwasher Failed to Reach Required Wash Temperature: The main kitchen’s low-temp chemical sanitizing dishwasher was observed running at 99 degrees F, below the manufacturer’s required 120 degrees F. Staff said the unit did not always reach the proper temp because hot water was being used by other departments, and management and maintenance were already aware of the issue. Logs showed the dishwasher water failed to reach 120 degrees F over multiple days, even though sanitizer levels were recorded within the required ppm range.
A resident with a right femur fracture and fall risk was found on the floor with increased R leg pain after a fall. Staff contacted the ER for guidance, gave Tylenol and ice, and delayed notifying the provider on call about the fall, possible fracture, and pain until later, with x-rays and ER transfer occurring afterward.
A resident was given Risperidone, but the record did not include an assessment or appropriate diagnosis supporting the antipsychotic use. The resident had Alzheimer’s disease, dementia, and anxiety, and MDS assessments noted antipsychotic use, with later documentation of physical behaviors. An administrative nurse confirmed the order came after a psych consult but lacked a diagnosis or MD progress note.
A nurse failed to assist and observe a resident with medication administration while the resident consumed pills from a medication cup in the dining room. The resident’s record had no physician order for SAM, and the care plan stated the resident was unable to self-administer medications due to dementia and a CVA history.
Failure to provide appropriate catheter care occurred for a resident with an indwelling Foley catheter when the physician's orders did not include the catheter or how often it should be changed. Staff changed the catheter after the resident reported severe pain at the insertion site, with pus-like urine, blood in the tubing, a clot noted after irrigation, and minimal urine return before the old Foley was removed and a new one inserted.
Missing Oxygen Order for a Resident: A resident returned to the facility after an acute hospital stay for pneumonia and CHF exacerbation and was observed wearing oxygen via nasal cannula at 2 L/min. The physician's orders did not include an oxygen order, and an administrative staff member confirmed the resident had no order for oxygen.
Infection control standards were not followed during high-contact care for multiple residents. CNAs provided toileting, brief changes, hygiene, and transfer assistance without gowns for residents on EBP, and another CNA applied PPE without hand hygiene before emptying a urine drainage bag and did not disinfect the floor after a urine spill. An admin nurse confirmed the expected PPE, hand hygiene, and spill cleanup practices.
Several residents' care plans were not updated to reflect current physician and dietary orders, resulting in conflicting or missing instructions for weight monitoring, ambulation, and diet. These discrepancies limited staff communication and continuity of care, as confirmed by an administrative nurse.
The facility did not establish a separate QAPI process or QA committee for the nursing home and instead relied on hospital-side quality meetings, with audits that did not address previously cited deficiencies. This resulted in ongoing noncompliance with federal requirements.
Nursing staff failed to follow physician orders and facility policies for medication administration, including administering an extra dose of pain medication to a resident after the order was changed, documenting insulin administration before giving it, not properly priming insulin pens, and administering insulin without privacy in a communal area.
Two residents who required total assistance for wheelchair transfers were transported without wheelchair foot pedals, resulting in their feet dragging or being positioned unsafely under the wheelchair. CNAs involved were unaware of the location of the necessary equipment, and an administrative nurse confirmed that foot pedals should have been used for residents unable to lift their feet. The facility could not provide a policy on foot pedal use when asked.
Facility staff did not consistently obtain or monitor monthly weights for two residents with significant medical conditions, resulting in missed identification and assessment of substantial weight fluctuations. Required weight variance reports were not completed, and staff failed to follow established policies for monitoring nutritional status.
Three insulin pens were found in a medication cart without required labeling, including the resident's name and the date opened, contrary to facility policy. An administrative nurse confirmed that staff are expected to label insulin pens with identifying information and dosing details.
Staff failed to disinfect mechanical stand lifts between uses after transferring multiple residents, instead moving unsanitized equipment between rooms and to storage. Although facility policy requires disinfection of multi-use devices after each use, staff either did not perform this task or believed it was housekeeping's responsibility, leading to lapses in infection control practices.
Failure to Inform Residents and Representatives About Psychotropic Medications
Penalty
Summary
The facility failed to fully inform residents or their resident representatives about treatment with psychotropic medications for 5 of 5 sampled residents reviewed for unnecessary medications. Record review showed that Resident #2 had physician orders for Buspirone, Duloxetine, Lorazepam, Mirtazapine, and Risperidone; Resident #4 had orders for Citalopram and Quetiapine; Resident #5 had orders for Quetiapine and Lorazepam; Resident #9 had orders for Lorazepam and Bupropion; and Resident #16 had orders for Seroquel and Memantine. For each of these residents, the medical record lacked documentation that the facility informed the resident and/or their representative of the risks, benefits, and alternatives of the prescribed treatment or obtained consent. The deficiency was identified through record review on all days of survey and confirmed in an interview with an administrative staff member on 04/08/26 at 12:15 p.m. The staff member acknowledged that the facility failed to fully inform the resident and/or their representatives regarding psychotropic medication treatment for Residents #2, #4, #5, #9, and #16.
Care Plans Not Kept Current for Multiple Residents
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of 6 of 12 sampled residents. Review of the facility policy titled Care Conference and Resident Centered Care Plan stated that each resident must have a comprehensive resident-centered care plan that is reviewed at least quarterly, as requested, or as needed, and kept current. Record review showed that Resident #2 had physician orders for Oxycodone and Risperidone, but the care plan did not identify problems or interventions for opioid and antipsychotic medication use. Resident #3 had orders for Spironolactone, Furosemide, Tramadol as needed, and Xarelto, but the care plan did not address diuretic use, opioid pain medication, or anticoagulation therapy. Resident #4 had orders for Hydrochlorothiazide and Xarelto, but the care plan did not identify problems or interventions for diuretic and anticoagulant use or for translation devices needed for communication. Resident #8 had an indwelling urinary catheter, but the care plan did not identify related problems, goals, or interventions. Resident #16 had orders for Lasix and Tramadol, but the care plan did not address diuretic and opioid pain medication use. Resident #21 had orders for Lasix and Seroquel, and progress notes documented that the resident had fallen from his chair. On observation, the resident was asleep at a dining room table, and nursing staff stated he had been there since lunch, had a recliner in his room that he would not sit in, and had also refused a recliner placed near his table. His care plan did not identify problems or interventions for diuretic and antipsychotic medications or his preference for spending most of the day at the dining room table.
Dishwasher Failed to Reach Required Wash Temperature
Penalty
Summary
The facility failed to ensure the low-temperature dishwasher in the main kitchen provided adequate heat and sanitization for dishes and utensils. Manufacturer specifications for the Energy Series “Green” Machine American Dish Service identified a water temperature of 120 degrees Fahrenheit, and the Ultra San Liquid Sanitizer instructions stated that for sanitizing tableware in low-temperature warewashing machines, the final rinse water must be at 100 ppm available chlorine and not exceed 200 ppm. During observation in the main kitchen, a dietary aide checked the dishwasher wash cycle temperature and obtained 99 degrees Fahrenheit, stating it does not always reach 120 degrees until later in the morning because other departments are using hot water for baths and laundry. A dietary supervisor stated administration and maintenance were aware of the low temperature, but no one had looked at the dishwasher. Review of the dishwasher temperature and chlorine logs from March 20 through April 6, 2026 showed the dishwasher water failed to reach 120 degrees Fahrenheit on those days, although the chlorine log showed 100-200 ppm. An administrative staff member stated maintenance was aware of the dishwasher concerns, and a dishwasher service representative confirmed that the low-temperature sanitizer requires a minimum wash temperature of 120 degrees Fahrenheit. The facility failed to address and correct the inadequate dishwasher temperature for 18 days.
Failure to Notify Physician After Resident Fall With Injury
Penalty
Summary
The facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident reviewed for a fall with injury. Resident #2 had diagnoses including a right femur fracture and was identified in the care plan as being at risk for falls due to cognitive loss. After the resident was found on the floor on her back at about 1:35 a.m., staff documented that she had no signs or symptoms of head injury but voiced increased pain in her right leg above the knee. She was lifted back to bed, her leg was immobilized with a rolled blanket, and the nurse contacted the emergency room for guidance rather than immediately notifying the provider on call. The record states the ER nurse advised giving Tylenol and ice and waiting until 8:00 a.m. to call the provider and obtain x-rays if the situation did not appear emergent. Tylenol was given around 2:00 a.m., ice was applied, and staff continued to monitor the resident's pain through the night. The progress note later documented that the provider on call and family were notified, x-rays were taken around 8:15 a.m., and the resident was transported to the ER at 9:00 a.m. A later note documented pain in the right leg, swelling, slight rotation, and a femur fracture report. An administrative nurse confirmed during interview that staff failed to notify the physician about the resident's potential fracture.
Unnecessary Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that Resident #2 remained free of chemical restraints by not documenting an assessment and appropriate diagnosis for the use of Risperidone, an antipsychotic medication. Resident #2’s medical record showed diagnoses of Alzheimer’s disease, dementia, and anxiety, and the medication list included Risperidone. The resident’s admission MDS identified no behaviors and the use of an antipsychotic medication, while a quarterly MDS later identified physical behaviors and the use of an antipsychotic medication. During interview, an administrative nurse confirmed the facility received an order for the antipsychotic medication after a psychiatric consultation, but the order lacked a diagnosis or physician progress note.
Failure to Assist and Observe Medication Administration
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for Resident #5 when the resident was observed self-administering medications without a physician order for self-administration. During observation, Resident #5 was seated in the dining room with a medication cup containing several pills on the meal tray and consumed the pills while the nurse administered medications to other residents. When asked whether Resident #5 was capable of self-administering medications, the nurse stated, "Yes, I believe so." However, the medical record lacked a physician order for self-administration of medication, and the care plan stated that the resident was unable to self-administer medications due to a dementia history and CVA. The nurse failed to assist and observe Resident #5 with the medications.
Missing Foley Order and Catheter Care
Penalty
Summary
Failure to provide appropriate care for a resident with an indwelling urinary catheter occurred when the resident had a catheter in place since admission, but the physician's orders did not include an order for the indwelling catheter or instructions for how often it should be replaced. The record showed facility staff changed the catheter 15 weeks after admission. A progress note documented that the resident reported severe pain at the catheter insertion site, urine in the tubing appeared pus-like with some blood, and the catheter was irrigated with approximately 40 cc of normal saline. A small clot was noted in the tubing after irrigation, urine return was minimal, and the resident reported minimal relief. The old Foley catheter was then removed and a new 16 Fr Foley catheter was inserted, with approximately 30 mL of cloudy yellow urine returned and the resident reporting relief from pain. An administrative staff member later confirmed that the physician's orders failed to include an indwelling Foley catheter and how often to change it.
Missing Oxygen Order for Resident
Penalty
Summary
Failure to obtain a physician's order for oxygen was identified for Resident #12. Review of the medical record showed the resident returned to the facility on 04/06/26 after an acute hospital stay for pneumonia and an exacerbation of congestive heart failure. Observation on 04/07/26 and 04/08/26 showed the resident wearing oxygen via nasal cannula at 2 liters per minute, but the physician's orders did not include an oxygen order. During an interview on 04/08/26 at 4:40 p.m., an administrative staff member confirmed that Resident #12 did not have an order for oxygen.
Infection Control and PPE Use During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards for 3 of 6 sampled residents during observed care. Review of the facility’s Enhanced Barrier Precautions policy stated that gown and glove use is required during high-contact resident care activities such as dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care for residents with MDRO infection or colonization. Resident #6 had a history of an MDRO, and during an observation a CNA wearing gloves assisted the resident with a brief change, adjusted the top sheet, and placed the overbed table next to the bed without applying a gown. Resident #5 had a non-pressure chronic ulcer of the left lower leg and had EBP signage and PPE on the door. During two separate observations, two CNAs entered the room with gloves and assisted the resident with toileting, brief changes, hygiene, and transfer back to the wheelchair, but did not apply gowns before the high-contact care. For Resident #8, a CNA applied PPE without performing hand hygiene before emptying the urine collection bag, and urine dripped onto a paper towel and soaked through to the floor; the CNA did not disinfect the floor after the spill. An administrative nurse confirmed she expected staff to wear the required PPE for high-contact care, perform hand hygiene before applying PPE, and disinfect the floor after a urine spill.
Failure to Update and Revise Care Plans to Reflect Current Physician Orders
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and physician orders for four of twelve sampled residents. For one resident with kidney disease and neuropathy related to diabetes mellitus, the care plan contained conflicting instructions regarding the frequency of weight monitoring, with both monthly and weekly weights documented. Another resident's care plan included contradictory ambulation instructions, listing both a restorative nursing ambulation program with a platform walker and assistance of two, as well as ambulation with assistance of one and a front-wheeled walker. A third resident's care plan also had conflicting orders for weight monitoring, with both monthly and weekly weights present. For a fourth resident, the care plan failed to include current physician orders for monthly weights and a specific diet order for a diabetic/regular consistency, low potassium diet. These discrepancies were identified through record review, facility policy review, and staff interviews. The facility's policies required care plans to be developed, reviewed, and revised by an interdisciplinary team to reflect current physician and dietary orders, and to be updated as needed. However, the care plans for these residents were not updated to remove outdated or conflicting information, or to include new orders, limiting staff's ability to communicate resident needs and ensure continuity of care. An administrative nurse confirmed that staff failed to update the care plans accordingly.
Failure to Establish and Utilize Nursing Home-Specific QAPI Process
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) process specific to the nursing home, as required by federal regulations. Review of state agency files and staff interviews revealed that the facility did not have a separate nursing home Quality Assurance (QA) committee and was not effectively utilizing QA activities to evaluate and identify problems, improve services or outcomes, or ensure compliance. Instead, QA audits conducted for the nursing home were brought to hospital meetings, and the issues currently audited did not address any of the deficiencies cited during the last standard survey. This lack of a dedicated and effective QAPI process resulted in continued noncompliance with federal requirements.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for multiple residents. For one resident with polyneuropathy, a physician's order for hydrocodone was changed from four times daily to twice daily, but the resident received a third dose after the order was changed. This was confirmed by review of the medication administration record and staff interview. Additionally, observations revealed that a nurse documented blood sugar and insulin administration on the medication administration record prior to actually administering the medications for two residents. The nurse also failed to prime insulin pens in accordance with facility policy, which requires the pen to be held pointing upward, instead priming them while pointing downward. Furthermore, insulin was administered to one resident in the dining room without privacy, in the presence of other residents, contrary to facility policy. An administrative nurse confirmed that these actions did not meet facility expectations or policy requirements.
Failure to Provide Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to provide necessary assistive devices, specifically wheelchair foot pedals, for two residents who were dependent on staff for wheelchair transfers and had documented lower extremity impairments. In one instance, a certified nurse aide (CNA) was observed transporting a resident whose left foot dragged on the floor and became twisted under the wheelchair due to the absence of a foot pedal. The CNA acknowledged that the left foot pedal was missing and was unaware of its location. The resident's medical record indicated functional limitations in range of motion and a care plan requiring total assistance for locomotion once in the wheelchair. In another case, two CNAs transferred a resident from a recliner to a different wheelchair that lacked foot pedals and proceeded to push the resident down the hallway. The resident's legs were observed to be positioned under the wheelchair, and the CNA admitted not knowing the location of the resident's assigned wheelchair. Both residents' care plans required total assistance once in the wheelchair, and an administrative nurse confirmed that staff were expected to apply foot pedals for residents unable to lift their feet. The facility was unable to provide a policy regarding foot pedal use when requested.
Failure to Monitor and Address Significant Weight Variances
Penalty
Summary
Facility staff failed to maintain acceptable parameters of nutritional status for two residents with documented weight variances. For one resident with chronic kidney disease and congestive heart failure, staff did not obtain monthly weights for three consecutive months and did not identify or assess significant weight fluctuations, including a 17-pound loss in one month and an 18.4-pound loss in less than a week. The resident was prescribed Furosemide and had physician orders and care plans specifying monthly weights, but these were not followed. Another resident, diagnosed with hypertension and also prescribed Furosemide, was not weighed as ordered in two separate months. The facility's policy required monthly weights, consistent weighing methods, and completion of weight variance reports, but these procedures were not followed. An administrative nurse confirmed that charge nurses were expected to monitor weights and acknowledged that monthly weight variance reports were not completed as required by policy.
Insulin Pens Not Properly Labeled in Medication Storage
Penalty
Summary
Surveyors observed that three insulin pens stored in a medication cart were not labeled with the resident's name or the date the pen was opened, as required by facility policy. The facility's policies on insulin pen use and storage specify that all insulin pens must have patient identification and the date opened clearly marked. During the observation, an administrative nurse retrieved the insulin pens and confirmed that they lacked the necessary labeling. The nurse also acknowledged that staff are expected to follow the policy and ensure insulin pens are properly labeled with identifying information and dosing details.
Failure to Disinfect Stand Lifts Between Resident Uses
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols regarding the disinfection of mechanical stand lifts used for resident transfers. Observations revealed that after transferring residents from the toilet to a wheelchair using stand lifts, staff members, including certified nurse aides and a nurse, did not sanitize the lift equipment between uses. In one instance, a CNA stated that housekeeping was responsible for cleaning the lifts, while administrative staff clarified that housekeeping only cleans the lifts twice a month and that staff are expected to clean them after each use. The facility's policy requires all multi-use medical devices, including mechanical lifts, to be disinfected between resident uses as part of the infection control program. Despite this, staff were observed moving unsanitized lifts between resident rooms and to storage areas after use. Interviews with administrative staff confirmed the expectation that staff should sanitize the lifts after each use, but this was not consistently practiced, as evidenced by the observations involving three different residents requiring stand lift transfers.
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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