St Gabriel's Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Bismarck, North Dakota.
- Location
- 4580 Coleman Street, Suite 1, Bismarck, North Dakota 58503
- CMS Provider Number
- 355126
- Inspections on file
- 20
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Gabriel's Community during CMS and state inspections, most recent first.
The facility failed to follow its own skin breakdown policy requiring notification of the attending provider, resident, and resident representative when new pressure injuries or lower extremity wounds develop or worsen. A resident with severe cognitive impairment developed MASD to the buttocks and a heel wound that progressed from suspected deep tissue injury to an unstageable pressure ulcer with black eschar, leading to an urgent podiatry referral. The medical record contained no documentation that the resident’s representative was informed of these wounds, their progression, or new treatment orders, and the family later reported they had not been told, despite an LPN confirming that families are supposed to be notified of new wounds, changes, and related treatments.
A resident with a history of bladder cancer, hematuria, and recent antibiotic use was not accurately coded on the MDS. The facility failed to document the cancer diagnosis, internal bleeding, and antibiotic administration in the appropriate MDS sections, as confirmed by staff interview.
Staff did not follow professional standards for insulin administration and failed to notify a physician when a resident's blood glucose readings were repeatedly above the ordered threshold. Additionally, a nurse was observed priming an insulin pen incorrectly, not in accordance with manufacturer instructions.
A resident with a history of constipation and impaired mobility did not receive required bowel management interventions after going several days without a bowel movement. Despite requesting prune juice, there was no documentation that nursing staff followed the facility's bowel protocol, leading to the resident being hospitalized for fecal impaction and a urinary tract infection.
A resident with dementia and a history of wandering exited the facility unsupervised after multiple documented episodes of confusion and exit-seeking behavior. Staff did not reassess the resident's elopement risk or update the care plan with individualized interventions, resulting in the resident being found off campus by a bystander.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) for two residents with indwelling Foley catheters, as required by facility policy. In both cases, staff assisted with resident transfers using gloves but failed to wear gowns during high-contact care activities, despite the expectation that gowns be used to prevent the transfer of MDROs.
The facility failed to follow infection control standards, with CNAs not performing hand hygiene between glove changes during resident care, and a nurse not donning appropriate PPE for a resident under Enhanced Barrier Precautions. These lapses were observed across multiple residents, indicating a breach in infection prevention protocols.
A resident with severe cognitive impairment repeatedly refused Ativan, an antianxiety medication, without the physician being notified. The facility lacked a policy for notifying physicians of medication refusals, and a family member expressed concern about the resident's ability to make informed decisions. A supervisory nurse was unaware if the physician had been informed of the refusals.
The facility failed to accurately code the MDS for three residents, affecting the reflection of their current status and needs. One resident's opioid medication was not coded, another's anticoagulant was incorrectly coded as an antiplatelet, and a third resident's hospice care was not recorded. Staff interviews confirmed these coding errors.
Failure to Notify Resident Representative of New and Worsening Wounds
Penalty
Summary
The facility failed to notify a resident’s representative of new and changing wounds and related treatment orders, as required by its own policy and regulatory expectations. The facility’s 2018 policy on Prevention and Treatment of Skin Breakdown required licensed nurses to perform weekly skin audits and, when a new pressure injury or lower extremity wound developed, to notify the attending provider, the resident, and the resident representative, and to educate them on the wound and care plan interventions. The policy also required notification of the attending provider, resident, and resident representative if a pressure injury failed to show progress in two weeks or deteriorated unexpectedly, with documentation reflecting these notifications. Record review for one resident with severe cognitive impairment (BIMS score of 3) identified wounds to the buttocks and right back heel, including moisture-associated skin damage (MASD) to the right medial buttock first noted as redness on 09/29/25 and later documented as new MASD with excoriation on 11/05/25. The right back heel was documented as a new suspected deep tissue injury on 11/11/25, which progressed to an unstageable pressure ulcer with mostly black eschar by 11/18/25, followed by an urgent podiatry referral order on 11/20/25. The medical record lacked documentation that the resident’s representative was notified of the buttock and heel wounds, their progression, or the new treatment orders. In interview, a family member stated they were not aware of the buttock wound or the heel ulcer, and a staff nurse confirmed that facility policy is to notify resident families of new wounds, changes in existing wounds, and related orders/treatments.
Failure to Accurately Code MDS for Resident with Cancer and Hematuria
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one resident, as identified through record review, review of the RAI User's Manual, and staff interview. The resident had a history of hospitalizations for urinary tract infection and hematuria, with an active diagnosis of malignant neoplasm of the bladder and was prescribed Bactrim DS, an antibiotic. Despite this, the significant change and quarterly MDS assessments did not reflect the resident's cancer diagnosis in Section I0100, nor did they indicate internal bleeding in Section J1550D, even though hematuria was present. Additionally, the quarterly MDS failed to code the use of an antibiotic in Section N0415F. These omissions were confirmed during an interview with an MDS staff member, who acknowledged the failure to accurately code the MDS. The lack of accurate coding meant that the resident's assessment did not fully reflect their current status, as required by the RAI User's Manual guidelines for active diagnoses, health conditions, and medication use during the specified look-back periods.
Failure to Follow Insulin Administration Standards and Physician Notification Protocols
Penalty
Summary
Staff failed to follow professional standards of practice in the administration and management of insulin for two residents. For one resident with diabetes mellitus, physician orders required blood sugar checks three times daily and notification of the primary care provider if blood glucose exceeded 400 mg/dl or dropped below 70 mg/dl. Despite multiple documented instances where the resident's blood sugar readings were above 400 mg/dl, there was no documentation that staff notified the physician as required by the orders. Additionally, during observations of insulin administration for another resident, a nurse was seen priming an insulin pen horizontally, contrary to the manufacturer's instructions, which specify that the pen should be primed with the needle pointing up to ensure accurate dosing. The facility's policy and administrative nurse confirmed that staff are expected to follow these procedures and notify physicians of out-of-range blood sugar levels.
Failure to Follow Bowel Management Protocol Resulting in Fecal Impaction
Penalty
Summary
The facility failed to provide appropriate care and services for a resident at risk for constipation, as required by its bowel management protocol and standing house orders. The resident, who had a history of constipation and impaired mobility, did not have a bowel movement for over four days. Despite the facility's policy requiring specific interventions such as offering prune juice, administering Senna, and escalating to a bisacodyl suppository and provider notification if no bowel movement occurred, the medical record showed that these steps were not implemented. On the third day without a bowel movement, the resident requested prune juice, but there was no documentation that further protocol interventions were carried out after this request. Subsequently, the resident experienced an unresponsive episode, was found to be pale and hypotensive, and was transferred to the hospital, where they were diagnosed with a urinary tract infection and fecal impaction. The resident's bowel movement log confirmed no bowel movement occurred between the last recorded event and the hospitalization. An administrative nurse confirmed that the medical record lacked evidence of the required bowel management interventions being implemented prior to the resident's hospitalization.
Failure to Supervise and Monitor Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a known history of dementia and wandering, resulting in an elopement incident. The resident had multiple documented episodes of confusion, wandering, and exit-seeking behaviors, including looking for her car and attempting to leave the facility. Despite these behaviors, the facility did not reassess the resident's risk for elopement or update her care plan to include individualized interventions to prevent wandering and elopement. The initial care conference did not address the resident's wandering, and staff failed to recognize and respond to the resident's escalating risk. On the day of the incident, the resident exited the facility using her wheeled walker and was later found off campus by a bystander, who notified the facility. The facility's policy required evaluation of residents' potential for wandering upon admission and as needed, but there was no documentation of a reassessment or implementation of additional interventions after the resident began exhibiting wandering and exit-seeking behaviors. The lack of timely identification and response to the resident's risk for elopement placed all residents at risk for similar incidents.
Failure to Follow Enhanced Barrier Precautions During Resident Transfers
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy for two residents who required these precautions due to the presence of indwelling Foley catheters and, in one case, a chronic wound. According to the facility's policy, staff are required to use gowns and gloves during high-contact resident care activities, such as transferring residents or providing wound care, to prevent the transfer of multi-drug resistant organisms (MDROs). For one resident, after wound care was completed with appropriate PPE, a CNA removed her gown and gloves, performed hand hygiene, and applied new gloves, but then assisted with transferring the resident using a ceiling lift without donning a gown as required by EBP protocol. In another instance, two CNAs assisted a second resident, also on EBP due to an indwelling Foley catheter, to transfer from bed to wheelchair. The CNAs wore gloves but did not wear gowns during the transfer, contrary to the facility's EBP policy. An administrative staff member confirmed during an interview that staff are expected to wear gowns during high-contact care activities for residents on EBP. These observations demonstrate that staff did not consistently follow the established infection prevention and control procedures for residents requiring EBP.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, particularly in the use of personal protective equipment (PPE) and hand hygiene, for six residents. Observations revealed that certified nurse aides (CNAs) did not perform hand hygiene between glove changes during resident care activities. For instance, a CNA assisting a resident with toileting and personal care did not sanitize hands between multiple glove changes, potentially spreading contaminants. Similar lapses were observed with other residents, where CNAs failed to perform hand hygiene after handling urine collection bags and before touching other surfaces. In another instance, a CNA did not perform hand hygiene between glove changes while assisting a resident with perineal care and transferring them to a wheelchair. Additionally, a CNA was observed not changing gloves or performing hand hygiene after handling a resident's urine collection bag and before adjusting the resident in bed. These actions were contrary to the facility's hand hygiene policy, which mandates hand cleaning before and after direct resident contact and after handling soiled items. Furthermore, a staff nurse failed to don appropriate PPE when entering a resident's room under Enhanced Barrier Precautions (EBP). The nurse was unaware of the resident's precautionary status, indicating a communication lapse regarding resident care protocols. The administrative nurse confirmed the resident was still on EBP, highlighting a failure in ensuring staff compliance with infection control measures.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal of a prescribed medication, Ativan, which is used for anxiety and seizures. This deficiency was identified for one resident who had a pattern of refusing the medication. The lack of notification to the physician may have prevented necessary adjustments to the resident's treatment or care. The facility did not have a policy in place regarding the notification of physicians when a resident refuses medication. The resident involved had severe cognitive impairment, was sometimes understood, and had a history of rejecting care. Diagnoses included aphasia, anxiety disorder, dementia, and epilepsy. The resident refused Ativan on multiple occasions, specifically the 1:00 a.m. dose on several days and the 7:00 a.m. dose on one day. A family member expressed concern that the resident was unable to make informed decisions about medication refusal. A supervisory nurse acknowledged that the doctor should be informed of repeated refusals but was unaware if this had been done for the resident in question.
Inaccurate MDS Coding for Medications and Hospice Care
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which is crucial for reflecting their current status and needs. For one resident, the medical record indicated a physician's order for Tramadol, an opioid, but the quarterly MDS did not reflect this medication. A nurse manager confirmed that the opioid should have been coded on the MDS. Another resident's medical record showed a physician's order for Eliquis, an anticoagulant, but the MDS incorrectly coded it as an antiplatelet. An administrative nurse acknowledged the incorrect coding in Section N of the MDS. Additionally, the facility failed to code hospice care for a resident who had a hospice consult and was receiving hospice services, as noted in the care plan. The significant change MDS did not reflect the resident's hospice care status. A nurse manager confirmed that hospice care was not coded on the MDS, indicating a lapse in accurately capturing the resident's care needs.
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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