Aspen Meadows Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 3155 Ave C, Billings, Montana 59102
- CMS Provider Number
- 275140
- Inspections on file
- 25
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Aspen Meadows Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
The facility did not maintain adequate nursing staff, resulting in delayed call light responses and improper use of mechanical lifts for resident transfers. Multiple residents experienced long wait times for assistance, and staff reported working short-handed and sometimes performing single-person transfers with mechanical lifts, despite care plans requiring two-person assistance. The facility lacked written policies on both call light response and lift use.
A resident was routinely left with medications at bedside to self-administer without a physician's order or an interdisciplinary team assessment, contrary to facility policy requiring both an order and a safety evaluation before permitting self-administration.
A resident with a lower leg infection, requiring dressing changes and use of a sit-to-stand lift for transfers, was admitted without a properly individualized baseline care plan. The care plan template used did not specify the level of assistance needed for functional activities or address the resident's specific needs for transfer assistance and wound care, as confirmed by staff interviews.
A resident with a persistently weak and strained voice, making communication difficult, did not have any interventions or focus areas related to this issue included in their care plan. Staff interviews confirmed the ongoing nature of the problem, but the care plan lacked measures to address the resident's communication difficulties.
A resident who recently had a right toe amputation due to vascular insufficiency and diabetes did not have their care plan updated to include the new surgical wound, wound care instructions, or mobility requirements, despite physician orders and staff awareness of the need for care plan updates.
A dependent resident with a history of falls waited 33 minutes for staff assistance after activating the call light to request help returning to bed due to leg pain. During this time, staff were observed socializing and assisting other residents but did not check on the resident or assess his needs, despite care plan interventions requiring timely response and anticipation of needs.
A pharmacist's recommendations for gradual dose reductions of two psychotropic medications for a resident were not addressed, and no documentation was found in the medical record to show that the recommendations were considered or acted upon. The responsible DON was no longer employed, and current staff could not provide the required documentation.
Staff did not consistently use required PPE, specifically gowns, while providing care to a resident with a history of MRSA and a current Stage 3 pressure ulcer, despite the presence of new PPE holders and facility policy requiring enhanced barrier precautions for such cases. Staff were unfamiliar with the new procedures and did not follow EBP protocols during high-contact care activities.
The facility failed to provide adequate assistance with ADLs for four residents, resulting in them being unkempt and experiencing body odor. A resident expressed dissatisfaction with receiving fewer baths than stipulated in their care plan, while another was observed checking for body odor due to missed showers. Staffing issues, including CNA shortages and schedule changes, contributed to the deficiency.
The facility failed to accurately administer and document controlled substances for two residents. One resident received incorrect doses of diazepam instead of hydromorphone, while another had discrepancies in Tramadol administration. A staff member acknowledged a recent narcotics diversion investigation but did not identify ongoing issues, attributing some errors to shift change timing.
A resident admitted with a right hip fracture and non-weight bearing status did not have a baseline care plan developed within 48 hours of admission. The facility failed to address the resident's specific needs, including nutrition, pain management, and therapy requirements. Staff changes in care planning responsibilities and uncertainty about software capabilities contributed to this oversight.
Licensed nurses in an LTC facility failed to adhere to medication administration standards, resulting in errors for two residents. One resident received Diazepam instead of Hydromorphone due to discrepancies in medication records, while another non-diabetic resident was mistakenly given insulin. The responsible nurse's competency was self-assessed and not verified by a registered nurse.
Two residents experienced significant medication errors due to improper administration by licensed nurses. One resident received Diazepam instead of Hydromorphone, and another non-diabetic resident was mistakenly given insulin. The errors were linked to discrepancies in medication records and lack of proper documentation verification.
A facility failed to provide adequate wound care and preventive measures for a resident with a pressure ulcer on the left heel. Dressing changes were not consistently documented as completed, and preventive measures like heel protector boots and proper bolster pillow placement were not consistently implemented. These deficiencies contributed to the worsening of the resident's pressure ulcer from nearly healed to a Stage III ulcer.
The facility failed to provide written transfer/discharge notices to three residents or their representatives prior to hospitalizations. Staff acknowledged that bed hold forms were occasionally not completed, and no notifications were found in the medical records for the residents in question.
The facility failed to remove expired medications from three medication carts, including insulin pens and various over-the-counter medications. Staff confirmed that monthly checks were conducted, but expired medications were still present, indicating a lapse in medication management.
The facility failed to maintain cleanliness in resident rooms and public restrooms, with observations revealing inadequate cleaning practices, debris under beds, dirty caulking, and ants. Residents reported infrequent and superficial cleaning, and staff interviews confirmed that the housekeeping department was short-staffed, leading to inconsistent cleaning schedules.
The facility failed to consistently provide and document restorative nursing services for two residents with a decline in functional status. One resident received restorative therapy only 11 times over nearly two months, missing 196 opportunities, while another received therapy only four times over three months, missing 67 opportunities. Staffing issues and unupdated restorative orders contributed to the inconsistency in care.
The facility failed to report an incident of staff arguing loudly in front of residents within the required timeframe, causing fear and distress. The report was delayed by five days due to an accidental deletion by a staff member.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
Insufficient Staffing Leads to Delayed Call Light Response and Improper Lift Use
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and improper use of mechanical lifts. Multiple staff and residents reported that the facility was frequently understaffed, with staff often required to pick up extra shifts or work with travel agency personnel to cover absences. Residents reported waiting between 20 to 40 minutes for call lights to be answered, and facility documentation confirmed several instances where call lights were not answered within the facility's expected 15-minute timeframe. The facility did not have a written policy on call light response available for review during the survey. Additionally, staff reported using mechanical lifts for resident transfers without the required two-person assistance, as specified in resident care plans. Staff admitted to performing single-person transfers with mechanical lifts when unable to find assistance, despite knowing this was against expected practice. The facility was unable to provide a written policy on lift use, and staff relied on personal judgment or video demonstrations rather than formal guidance. One resident confirmed that sometimes only one staff member assisted with transfers, contrary to their care plan requirements.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A staff member prepared medication for a resident and placed it in a medication cup on the resident's bedside table while the resident was sleeping, stating that the resident preferred to take her medications when she was ready. The staff member indicated that this was a common practice, as the resident often did not want to take medications in front of staff. The resident confirmed that staff frequently left medications in her room for her to take at her convenience, and that staff did not always observe her taking them. Review of the resident's electronic medical record revealed there was no physician's order authorizing self-administration of medications, nor was there documentation of a safety assessment to determine if the resident was capable of safely self-administering her medications. Facility policy requires a prescriber's order and an interdisciplinary team assessment before permitting residents to self-administer medications, but these steps were not completed for this resident.
Failure to Develop Resident-Centered Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a resident-centered baseline care plan for one resident within 48 hours of admission. The resident, who was observed sitting in a wheelchair with wraps on both legs due to a lower leg infection, reported experiencing pins and needles from his toes to his hips and stated that staff changed his leg wraps every couple of days. He also indicated that he used a sit-to-stand lift for transfers and was working with therapy to regain strength. Review of the baseline care plan revealed that a template was used, but it did not specify the amount of assistance required for functional activities, nor did it address the resident's use of a lift for transfers or the need for dressing changes related to his leg infection. Staff interviews confirmed that the nurse was responsible for completing the care plan template and that physical therapy would revise it as needed, but the necessary individualized details were missing.
Failure to Address Resident's Communication Needs in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan addressing a resident's communication difficulties. During multiple observations and interviews, it was noted that the resident had a persistently weak, strained voice, making it difficult for others to understand him. The resident expressed a desire to see a specialist regarding his voice and reported ongoing difficulty being understood. Staff interviews confirmed that the resident's voice had been weak for an extended period, but staff were unaware of the cause. Review of the resident's care plan revealed that it did not include any focus area or interventions related to the resident's communication challenges, despite these ongoing issues being evident to both the resident and staff.
Failure to Update Care Plan for New Surgical Wound
Penalty
Summary
The facility failed to update the care plan for a resident who had recently undergone a surgical amputation of the right toes due to vascular insufficiency and diabetes. Despite physician progress notes and post-operative wound care orders specifying non-weightbearing status, use of a postop shoe, Hoyer lift mobilization, and detailed wound dressing instructions, the resident's care plan did not include any information regarding the surgical procedure, wound care, wound monitoring, or specific mobilization requirements. Observations confirmed the presence of a right foot dressing, and staff interviews indicated that care plans should be updated whenever resident changes occur, but this was not done for the resident in question.
Delayed Response to Call Light for Dependent Resident
Penalty
Summary
A dependent resident with a history of falls and significant ADL needs was observed waiting 33 minutes for assistance after activating his call light to request help returning to bed due to leg pain. During this period, staff were seen engaging in social conversations in the hallway and assisting other residents, but did not check on the resident or assess his needs. The resident expressed frustration about frequent long waits for assistance, difficulty calling out due to a weak voice, and being left alone in the bathroom for extended periods. The resident's care plan indicated he was at risk for falls and required staff assistance for most basic needs, including mobility and toileting. Interventions included ensuring the call light was within reach and anticipating his needs. Despite these interventions, staff did not respond to the call light within the facility's expected 15-minute timeframe, nor did they check on the resident during the wait. The facility was fully staffed at the time, and the call light system did not provide a historical log for review.
Failure to Address Pharmacist's Recommendations for Psychotropic Medication Dose Reductions
Penalty
Summary
The facility failed to ensure that a pharmacist's recommendations for gradual dose reductions of two psychotropic medications, quetiapine and clonazepam, were addressed for one resident. The pharmacist's medication regimen review, dated 10/9/24, included recommendations for gradual dose reductions, but the only documentation found was a handwritten note stating 'follows psych,' dated 10/16/24. During interviews, staff indicated that the previous Director of Nursing (DON), who was responsible for medication review follow-up, was no longer employed at the facility, and current staff were unable to locate any medical record documentation addressing the pharmacist's recommendations. Despite requests for documentation, none was provided prior to the end of the survey.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP). During observations, two staff members assisted a resident with a history of MRSA infection and a current Stage 3 pressure ulcer on the left foot, without wearing gowns as required by EBP protocols. The resident was unaware of the purpose of the newly installed PPE holder on the door, and staff indicated unfamiliarity with the new PPE procedures, stating that the holders had just been installed and that they believed the gowns were only necessary for nurses during dressing changes. Further interviews revealed that staff were not consistently implementing EBP throughout the facility, despite recent re-education efforts. Review of the facility's infection control policy confirmed that EBP requires the use of gowns and gloves during high-contact care for residents with chronic wounds or a history of multidrug-resistant organism (MDRO) infection. The lack of adherence to these protocols was directly observed and acknowledged by staff.
Failure to Provide Adequate Assistance with ADLs Due to Staffing Issues
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, resulting in them being unkempt and experiencing noticeable body odor. Resident #8, who is alert and oriented, expressed dissatisfaction with receiving fewer baths than his care plan stipulates, which is five baths per week. He reported typically receiving only two baths weekly and no additional wash-ups between baths. Resident #65 was observed checking for body odor due to missing a scheduled shower, and her care plan indicated she should receive two baths weekly. However, records showed she had only received one bath in a two-week period. Resident #23, who requires assistance with most of his care, was noted to have a strong body odor and appeared unkempt, with records indicating he had not received his weekly bath as per his care plan. Resident #39 also reported not receiving her scheduled baths, which made her feel neglected and caused discomfort. The deficiency was attributed to staffing issues within the facility. Staff member O acknowledged that staff call-offs led to a shortage of certified nurse assistants (CNAs), resulting in bath aides being reassigned to routine resident care instead of completing scheduled baths. Additionally, staff member B mentioned that a new bath aide had been hired, and the shift schedule was changed from eight-hour to twelve-hour shifts. However, personal time off requests from a bath aide further disrupted the bathing schedule, leading to unmet resident needs. The facility was in the process of revising the bathing schedules to better align with residents' personal needs.
Controlled Substance Administration and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate administration, accounting, and documentation of controlled substance medications for two residents. For one resident, a nurse made a medication error by administering two doses of diazepam instead of the prescribed hydromorphone. The medication administration record showed discrepancies, with one dose of diazepam recorded instead of two, and three doses of hydromorphone recorded when only one was signed out. Additionally, the resident missed two of the three ordered doses of hydromorphone on the same day. Another resident was prescribed Tramadol to be administered three times daily, but the narcotic medication logs showed inconsistencies, with fewer doses documented than administered. During an interview, a staff member acknowledged a recent narcotics diversion investigation and mentioned that audits were conducted consistently for a time. However, the staff member did not identify any problems with narcotics counts not matching the medication administration record and was not alerted by the pharmacy of any discrepancies. The staff member was aware of the medication error for the first resident and attributed some errors to the timing of medication administration coinciding with staff shift changes, leading to confusion about responsibility.
Failure to Develop Timely Baseline Care Plan for Resident with Non-Weight Bearing Status
Penalty
Summary
Facility staff failed to identify and address care concerns for a resident who was admitted with a right lower extremity non-weight bearing status. The resident, who had sustained a right hip fracture from a fall, was admitted to the long-term care center for additional physical and occupational therapy services. Despite the resident's condition requiring specific attention, the facility did not develop and implement a baseline care plan within 48 hours of admission to address the resident's care needs, including nutrition, pain management, weight bearing status, and therapy needs. During interviews, it was revealed that the responsibility for completing the baseline care plan had shifted from the MDS nurse to the interdisciplinary team during the facility's morning meeting. However, there was uncertainty about whether the computer software used for care planning could accommodate entries for a resident's weight bearing status. The baseline care plan that was eventually completed failed to include critical focuses, goals, or interventions related to the resident's specific needs, highlighting a significant oversight in the facility's care planning process.
Medication Administration Errors in LTC Facility
Penalty
Summary
Licensed nurses failed to provide competent nursing services by not adhering to professional standards of medication administration for two residents. For one resident, there was a discrepancy between the physician's order and the medication administration record regarding Diazepam administration. The resident was supposed to receive Diazepam intramuscularly for seizures, but the narcotics medication log indicated an oral administration. A medication error occurred when Diazepam was administered instead of the prescribed Hydromorphone, and the narcotics log showed that Hydromorphone was not removed from the cabinet as required. The nurse responsible, identified as staff member Q, had self-assessed their competency in medication administration, but this was not verified by a registered nurse, and documentation skills were not assessed. Another incident involved a resident who was mistakenly administered insulin by a nurse, despite the resident stating they had never taken insulin and were not diabetic. The nurse did not respond to the resident's statement and proceeded with the injection. The facility terminated the nurse's contract following the incident. The medication error was reported by the resident to a certified medication aide, and it was documented in the facility's Medication Error Report.
Medication Administration Errors in LTC Facility
Penalty
Summary
Licensed nurses failed to administer medication according to professional standards for two residents, leading to significant medication errors. For one resident, there was a discrepancy between the physician's order and the medication administration record regarding Diazepam administration. The resident was supposed to receive Diazepam intramuscularly for seizures, but the narcotics log indicated an oral dose. On one occasion, the resident received Diazepam instead of the prescribed Hydromorphone, and the narcotics log showed that Hydromorphone was not removed from the cabinet as required. The nurse responsible had documented proficiency in medication administration but lacked verified competency in documentation. Another resident reported receiving an insulin injection despite not being diabetic. The resident informed the nurse of this, but the nurse proceeded with the injection. The resident experienced a drop in blood glucose level, which was managed with orange juice and breakfast. The nurse involved did not report the incident, and the resident required no further interventions. The facility documented the error and reported it to the appropriate authorities.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate wound care and implement physician-ordered interventions for a resident with a pressure ulcer on the left heel. The resident's treatment orders included specific dressing changes and the use of a wound vac, which were not consistently documented as completed. Observations revealed that the dressing changes were not performed as ordered, and there was a discrepancy in documentation by staff members regarding who completed the dressing changes. This lack of adherence to the prescribed wound care regimen contributed to the deterioration of the resident's pressure ulcer from nearly healed to a Stage III ulcer. Additionally, the facility did not consistently implement preventive measures for pressure ulcer management, such as the use of heel protector boots and proper placement of a bolster pillow. The resident was observed without the heel protector boots on one occasion, and the bolster pillow was improperly placed under the knees instead of the calves, contrary to the wound clinic provider's instructions. Documentation of the use of these preventive measures was inconsistent, with some refusals noted but not consistently recorded. These deficiencies in care and documentation contributed to the worsening of the resident's pressure ulcer condition.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices to residents or their representatives prior to hospitalizations. Specifically, three residents did not receive the required notices before being transferred to the hospital. Staff member B indicated that transfer/discharge notices were typically completed before all resident discharges, but acknowledged that bed hold forms were occasionally not completed. During the survey, it was confirmed that no transfer/discharge notifications were found in the medical records for the three residents in question. No additional information was provided by the end of the survey.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to remove expired medications from three medication carts, which had the potential to affect all residents receiving medication from these carts. During an observation, medication cart #1 was found to contain an opened Novolin insulin pen dated 2/17/24 and an opened Lispro insulin pen dated 2/26/24, both of which should have been discarded after 28 days. Further inspection of three medication carts revealed additional expired medications, including allergy relief tablets, Geri-dryl, Aspirin, Calcium Citrate, Oyster shell, fiber capsules, Zinc, and Calcium with Vitamin D. Staff interviews confirmed that the medication carts and storage rooms were checked for expired supplies once per month by the pharmacy representative, and nurses also conducted a monthly review for outdated medications. However, these expired medications were still present, indicating a lapse in the facility's medication management practices.
Facility Fails to Maintain Cleanliness in Resident Rooms and Public Restrooms
Penalty
Summary
The facility failed to provide clean resident rooms and public restrooms, affecting multiple residents and potentially all staff and visitors. Observations revealed that resident rooms were not adequately cleaned, with items such as medication cups, plastic water cups, and pills found under beds. Residents reported that their rooms were only superficially cleaned, with beds rarely moved to clean underneath. Specific instances included a resident's room where debris and a pill remained under the bed for several days, and another room where orange-colored debris was observed on the floor for consecutive days. Public restrooms were also found to be inadequately cleaned. One restroom near the main entrance lobby had brown splattered debris in the toilet bowl, pieces of toilet tissue and paper towels on the floor, and water stains on the mirror. These conditions were observed to be unchanged over several days. Staff interviews revealed that the housekeeping department was short-staffed, leading to inconsistent cleaning schedules. Additional observations included rooms with dirty caulking, ants, and unclean surfaces. Residents reported infrequent and inadequate cleaning, with some areas not being cleaned for extended periods. One resident's room had a recliner piled with equipment and supplies, and another room had a bathroom with a sticky yellow substance on the floor and a concentrated urine-like odor. Staff interviews confirmed that the facility was understaffed in housekeeping, contributing to the deficiencies in cleanliness and hygiene.
Failure to Provide Consistent Restorative Nursing Services
Penalty
Summary
The facility failed to consistently provide and document restorative nursing services for residents with a decline in functional status. Resident #49 reported feeling a loss of strength and mobility, stating that they used to walk with assistance but now doubted their ability to do so. The resident's medical records showed a significant decline in functional status, and the restorative services prescribed were not consistently provided. Specifically, the resident received restorative therapy only 11 times between 2/19/24 and 4/10/24, missing 196 opportunities for restorative services. Staff interviews revealed that the facility had staffing issues and had not updated the restorative orders to reflect the limited availability of aides, leading to the inconsistency in care provision. Similarly, Resident #12 expressed a desire to regain strength and improve mobility but reported being confined to a wheelchair. The resident's medical records indicated a decline in functional status, and the care plan included restorative services to improve strength, ROM, and transfer abilities. However, the resident received restorative therapy only four times over three months, missing 67 opportunities for restorative services. Staff acknowledged the issues with the restorative program, citing recent staff departures and ongoing efforts to adjust schedules and improve the program.
Failure to Timely Report Incident
Penalty
Summary
The facility failed to report a facility-reported incident within the required timeframe for one of the sampled residents. The incident involved staff arguing loudly in front of residents, causing fear and distress. The incident was documented in a nurse's progress note and reported by a resident, who expressed feeling scared by the loud argument. The initial report of the incident was delayed by five days due to an error by a staff member who accidentally deleted the report instead of submitting it. The facility's policy mandates that any employee, manager, agent, operator, owner, or contractor must report incidents immediately, within two hours if the event involves abuse or results in serious bodily injury, or within 24 hours if it does not. The incident in question did not involve abuse or result in serious bodily injury, but it was still reported five days late. This delay in reporting was acknowledged by a staff member during an interview, who admitted to accidentally deleting the initial report.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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