Strasburg Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Strasburg, North Dakota.
- Location
- 409 S 3rd St, Strasburg, North Dakota 58573
- CMS Provider Number
- 355049
- Inspections on file
- 18
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Strasburg Nursing Home during CMS and state inspections, most recent first.
Failure to observe medication administration occurred when a nurse prepared a resident's meds, stated the resident was SAM, and left pills on the table without assisting or watching the resident take them. The resident's record showed the resident did not wish to participate in SAM, and another nurse confirmed the resident should have been observed or assisted with taking the medications.
Medication labels did not match the MAR for one resident during a med pass. An RN prepared dicyclomine for a resident whose order and MAR showed 20 mg BID, but the medication label stated half tablet, or 10 mg BID. The nurse confirmed the order and administered 20 mg, and an administrative nurse later confirmed the mismatch.
Infection control standards were not followed during dressing changes for two residents. One resident on EBP for a suprapubic catheter with chronic cellulitis and wound drainage had a nurse perform glove changes without hand hygiene and without a gown, while also handling wound supplies without hand hygiene. Another resident with a right heel pressure ulcer had dressing supplies, including gauze, scissors, tape, and cleaning solutions, placed directly on a cloth chair instead of a clean surface.
A resident reported missing $100 after placing it in a drawer before taking a shower. Despite the facility's policy requiring reporting of such incidents, the administrative nurse confirmed the incident was not reported to the SSA, placing residents at risk for misappropriation of property.
A resident reported $100 missing after a shower, but the facility failed to initiate an investigation as required by their policy. Despite the resident's intact cognition and confirmation from his daughter about the money, no investigation was conducted, leaving the issue unresolved.
The facility did not follow professional standards for insulin pen preparation and administration for two residents. Nurses failed to prime the insulin pens correctly by not holding them upward, contrary to the facility's policy. An administrative staff member confirmed the expectation for staff to adhere to this policy.
A facility failed to provide necessary personal hygiene assistance to a resident with dementia who required setup help and verbal reminders. A nurse helped the resident change clothes but did not assist with hygiene, stating assistance would be given when the resident allowed it. An administrative nurse expected the nurse to assist with hygiene during dressing.
A facility failed to adhere to its catheter care policy for a resident with an indwelling urinary catheter. The policy required catheter bags to be emptied at the end of each shift, but observations showed the bag was not emptied as required, leading to discomfort for the resident. The resident had a history of urinary issues, and the catheter bag was found to contain excessive urine on multiple occasions. An administrative staff member confirmed the expectation for catheter bags to be emptied at least once per eight-hour shift.
The facility failed to follow infection control standards for a resident with a Foley catheter, as CNAs did not use gowns or gloves during transfers and did not perform hand hygiene after removing gloves. The administrative nurse confirmed the lack of staff education on enhanced barrier precautions, leading to potential infection spread.
Failure to Observe Medication Administration for Resident Not Participating in SAM
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 14 residents reviewed for self-administration of medication, Resident #21. The facility policy stated that a licensed nurse would complete the self-administration of medications screen, the interdisciplinary team would make the determination based on the screen, and reassessment would be completed quarterly and as needed. Resident #21's record showed a self-administration assessment dated 01/19/26 that lacked the resident's choice to not self-administer medications, and a progress note dated 01/28/26 stated that the resident did not wish to participate in SAM. During observation on 04/01/26 at 7:41 a.m., a nurse prepared the resident's medications, stated that he was SAM, placed a cup of pills on the table, mixed a powdered stool softener in water, and returned to the medication cart without assisting or observing the resident take the medications. A staff nurse later confirmed that the nurse should observe or assist Resident #21 with taking his medications.
Medication Label Did Not Match MAR for One Resident
Penalty
Summary
Medication labels and provider orders did not match for one resident during a medication pass. Resident #21 had a provider order dated 02/11/26 to increase dicyclomine to 20 mg twice a day. During observation on 04/01/26 at 7:41 a.m., Nurse #5 prepared the resident’s medications, and the MAR identified dicyclomine 20 mg twice a day. The medication label, however, indicated to administer half a tablet, or 10 mg, twice a day. The nurse confirmed the provider’s order and administered 20 mg. During an interview later that morning, an administrative nurse confirmed that Resident #21’s dicyclomine label did not match the resident’s MAR.
Infection Control Failures During Dressing Changes
Penalty
Summary
The facility failed to follow infection control and prevention standards during dressing changes for two residents. Review of facility policy showed that enhanced barrier precautions required gown and glove use during high-contact resident care activities, including chronic wound care and dressing changes, and the dressing change policy required hand hygiene before and after glove use and stated that dressings and supplies were never to be placed on the resident's bed, with an over-the-bed table to be used and disinfected before and after the procedure. Resident #2 had enhanced barrier precautions related to a suprapubic catheter with chronic cellulitis and wound drainage around the site. During observation, a nurse performed hand hygiene, donned gloves, removed a soiled dressing, removed gloves, and then applied clean gloves without performing hand hygiene before cleansing and redressing the site. The nurse did not wear a gown during the dressing change and later removed gloves, did not perform hand hygiene, placed wound supplies into a basket and into the nightstand drawer, and applied the resident's shoes before performing hand hygiene and leaving the room. Resident #24 had a pressure ulcer to the right heel, and during observation a nurse removed dressing supplies from a plastic basin, opened gauze, and placed the gauze, scissors, tape, and cleaning solutions directly on a cloth chair instead of using a clean surface.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of resident property to the State Survey Agency (SSA) within the required 24-hour timeframe. This deficiency involved a resident who reported missing $100, which was given to him as a Christmas gift. The resident had received the money from his daughter after she cashed a check for him. He placed the money in a drawer before taking a shower, and upon returning, found the money missing. Despite the resident's report to the nursing staff and their subsequent search, the money was not found. The facility's policy mandates that any alleged violations, including misappropriation of resident property, be reported to the SSA in accordance with state law. However, an administrative nurse confirmed that the incident was not reported to the SSA. The failure to report the alleged violation placed the resident and potentially other residents at risk for misappropriation of property. The resident's medical records and interviews with the resident and his family corroborated the timeline and details of the incident.
Failure to Investigate Missing Resident Property
Penalty
Summary
The facility failed to initiate an investigation into an alleged violation of misappropriation of resident property for a resident who reported missing money. The facility's policy on misappropriation of resident property requires a thorough investigation of all allegations, but this was not followed in the case of the resident who reported $100 missing after a shower. Despite the resident's report and the involvement of his daughter, who confirmed the money was given to him, the facility did not start or complete an investigation. Interviews with the resident and his family indicated that the resident had intact cognition and it was not typical for him to misplace items. The resident reported the missing money to the nurse, and although staff searched for the money, it was not found. The administrative nurse confirmed that no investigation had been initiated, which is a failure to adhere to the facility's policy and protect the resident's property.
Failure to Follow Insulin Pen Priming Procedure
Penalty
Summary
The facility failed to adhere to professional standards of practice in the preparation and administration of insulin for two residents. During observations, it was noted that a nurse did not prime the insulin pen correctly for Resident #12, as the pen was not held upward during priming. Similarly, another nurse failed to prime the insulin pen upward for Resident #9. The facility's policy on insulin pen usage, which was reviewed, clearly states that the pen should be primed by holding it with the needle pointed upward. An administrative staff member confirmed that the expectation was for staff to follow this policy.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who required assistance with personal hygiene received the necessary support. The resident, who has a self-care performance deficit related to dementia, was observed needing setup help and verbal reminders for personal hygiene. During an observation, a nurse assisted the resident in selecting clothing and changing out of pajamas but did not provide the needed assistance or verbal reminders for personal hygiene. When questioned, the nurse indicated that assistance would be provided when the resident allowed it. An administrative nurse later stated that the expectation was for the nurse to assist the resident with personal hygiene while helping with dressing.
Failure to Adhere to Catheter Care Policy
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter. The facility's policy required catheter bags to be emptied at the end of each shift, which is three times per day. However, observations and record reviews revealed that the resident's catheter bag was not emptied as per the policy. On one occasion, the catheter bag contained approximately 1200 cc of urine at 4:43 p.m. and increased to 1300 cc by 5:50 p.m., with the resident expressing discomfort. The bag was eventually emptied at 7:53 p.m., containing 2000 cc of urine. Additionally, records showed that from January 6th to January 20th, the catheter bag was emptied only twice in a 24-hour period on four separate days. The resident involved had a medical history that included obstructive and reflux uropathy, benign prostatic hyperplasia, and a history of urinary tract infections. The care plan indicated the resident had an indwelling suprapubic catheter due to urinary obstruction. During an interview, an administrative staff member confirmed that the catheter should have been emptied before 8:00 p.m. and stated that certified nurse assistants were expected to empty catheter bags at least once per eight-hour shift. This failure to adhere to the facility's catheter care policy could lead to urinary tract infections, unnecessary discomfort, and urinary retention or obstruction.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding enhanced barrier precautions (EBP) and hand hygiene, for a resident with a Foley catheter. The facility's policy required the use of gown and gloves during high-contact activities for residents at increased risk of multidrug-resistant organism (MDRO) acquisition. However, observations revealed that certified nurse aides (CNAs) did not don gowns or gloves when transferring the resident from a recliner to a wheelchair and from a toilet to a wheelchair. Additionally, a CNA failed to perform hand hygiene after removing gloves and before donning new gloves during the resident's care activities. The administrative nurse confirmed that the facility did not educate staff on the proper use of gown and gloves for residents under enhanced barrier precautions. The lack of adherence to the facility's policy and the failure to perform hand hygiene as required by the policy were observed during multiple instances of resident care. These deficiencies in infection control practices have the potential to spread infection throughout the facility.
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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