Awe Kualawaache Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crow Agency, Montana.
- Location
- 10131 S Heritage Rd, Crow Agency, Montana 59022
- CMS Provider Number
- 275153
- Inspections on file
- 22
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Awe Kualawaache Care Center during CMS and state inspections, most recent first.
The facility failed to ensure the infection preventionist was adequately trained and knowledgeable, did not maintain documentation of infection control audits, and lacked a comprehensive water management program to prevent Legionella. Staff did not consistently follow proper transmission-based precautions for a resident with C. diff, and a nurse did not perform hand hygiene between glove changes during wound care. These deficiencies increased the risk of infection for all residents.
The facility did not notify the State Ombudsman Office or provide required ombudsman contact information to residents during hospital transfers or discharges. Staff interviews revealed a lack of awareness about these requirements, and review of transfer/bed hold notices for several residents confirmed the omission. The facility was unable to provide documentation of ombudsman notification for these events.
A resident in a LTC facility was physically restrained for an hour without following proper procedures. The charge nurse directed staff to restrain the resident to administer an antipsychotic injection due to aggressive behavior. The facility failed to obtain a practitioner's order, ensure the least restrictive restraint, and provide ongoing monitoring, violating F604 - Restraints guidelines.
A facility failed to update a resident's care plan to include his preference for male staff who spoke his native Crow language, which reduced his agitation and aggression. Despite staff awareness and discussion of this preference, it was not documented in the care plan, leading to a deficiency in personalized care.
A facility failed to ensure nursing staff were adequately trained and competent in managing a resident with aggressive behaviors and the use of restraints. A resident was physically restrained for an hour without proper oversight after an intramuscular antipsychotic injection. The nurse involved was a new graduate, and staff reported a lack of training in restraint use, with no documentation of training in their personnel files.
The facility's assessment failed to accurately reflect the care required for residents with behavioral health needs, as staff expressed concerns about their ability to manage aggressive behaviors. Despite the facility's claims of offering mental health services, interviews revealed a lack of appropriate skills and resources to care for these residents.
The facility failed to provide adequate behavioral health training for staff, leading to unawareness of care plan interventions for residents with aggressive behaviors. Staff expressed uncertainty in handling incidents, with some relying on seeking help from the DON or other nurses. Residents with known behavioral issues, such as one with paranoid schizophrenia, were monitored by sitters who were not informed or trained on managing behaviors. The lack of training and awareness contributed to the deficiency identified by surveyors.
A resident was involved in a physical altercation with a CNA, who aggressively pulled the resident's hands behind her back and pulled her to the ground. The incident was captured on security footage, showing the resident pushing her walker towards the CNA, who then restrained and pulled the resident down, despite other staff attempting to de-escalate the situation. The CNA was identified as easily angered and a bully, leading to their removal and termination.
The facility failed to assess the root causes of a resident's behavioral outbursts and did not provide necessary mental health services for another resident with schizophrenia. One resident exhibited aggression without root cause assessments, while another lacked documentation of receiving required outpatient mental health services. Staff reported challenges in coordinating care with the only available provider.
A facility failed to limit PRN psychotropic medications to 14 days or provide documented rationale for extended use. A resident received Ativan and Olanzapine without physician documentation for continued use or stop dates. Staff indicated the physician visited monthly and pharmacy reviews for stop dates were pending.
The facility failed to update the care plan for a resident with a chronic non-pressure ulcer and did not include daily weight monitoring as instructed by an emergency room physician. Staff interviews revealed that care plan updates were delayed due to the resignation of the previous DON.
The facility failed to ensure nurse competencies for wound care, resulting in a resident with diabetes and chronic ulcers not receiving necessary treatments for several days. The admitting physician's orders were incomplete, and the wound clinic could not be contacted over the weekend and holiday for clarification.
The facility failed to accurately submit PBJ data for RN coverage and 24-hour licensed nurse coverage for multiple days in Quarter One of Fiscal Year 2024. Discrepancies were found between the submitted data and employee timecards, and staff interviews revealed that the data was based on outdated schedules.
Infection Control Deficiencies: Training, Waterborne Illness Prevention, and PPE Compliance
Penalty
Summary
The facility failed to ensure that the infection preventionist was properly trained and knowledgeable in key infection control practices. The infection preventionist reported not receiving the required education for the position, was unable to provide documentation of hand hygiene and PPE audits, and was unsure about the frequency of mandatory infection control education. Additionally, the infection preventionist did not have quick reference materials for determining appropriate precautions for specific infections, was uncertain about which diseases were reportable to the state, and incorrectly stated that alcohol-based hand rubs were preferable to handwashing for Clostridioides difficile (C. diff) cases, contrary to CDC guidance. The facility also failed to implement and document safety measures to prevent waterborne illnesses such as Legionella. Staff interviews revealed that there was no log of toilet flushing or clear understanding of the requirements for weekly flushing to prevent Legionella growth. Testing for Legionella was limited to swab testing a countertop in the kitchen, and there was no evidence of a comprehensive water management program as outlined in facility policy, including monitoring, control limits, and documentation. Deficiencies were also observed in the application of transmission-based precautions and hand hygiene. One resident with C. diff was placed on droplet precautions, but staff entered the room without appropriate PPE, left the door open, and were unclear about the correct precautions. Another staff member failed to perform hand hygiene between glove changes while providing wound care to a resident, despite facility policy requiring handwashing after glove removal. These lapses in infection control practices had the potential to affect all residents in the facility.
Failure to Notify State Ombudsman and Provide Contact Information During Resident Transfers
Penalty
Summary
The facility failed to notify the State Ombudsman Office when residents were transferred to the hospital or discharged, and did not provide residents with the required contact information for the State Ombudsman Office. This deficiency was identified for three sampled residents who experienced transfers or discharges, as their transfer/bed hold notices lacked the necessary ombudsman contact details. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman and to include their contact information on transfer/discharge forms. Additionally, the facility was unable to provide documentation showing that the ombudsman had been notified of these transfers or discharges. Facility policy indicated that notice of transfer or discharge should be provided to the resident, their representative, and the LTC ombudsman when practicable. However, review of the records for the affected residents showed that this policy was not followed, as the required notifications and contact information were missing. Staff confirmed that notification to the ombudsman was only done in specific circumstances, such as incident reports, and not routinely for all transfers or discharges.
Improper Use of Physical Restraints on Resident
Penalty
Summary
A deficiency was identified in a long-term care facility where a resident was physically restrained without following the required procedures. The incident involved a resident who was acting aggressively towards staff and other residents. The charge nurse directed staff to physically restrain the resident to administer an intramuscular injection of an antipsychotic medication. The restraint continued for an hour, which exceeded the initial 15 minutes intended for the medication to take effect. The staff did not ensure the least restrictive restraint was used, nor did they verify with the nurse if it was safe to continue restraining the resident. The facility failed to follow the necessary steps outlined in the State Operations Manual, Appendix PP, under F604 - Restraints. These steps include obtaining an order from a practitioner during or immediately after the application of the restraint, ensuring the restraint is a last resort, and providing ongoing monitoring and assessment of the resident's condition. Additionally, the facility did not document the incident properly, including the resident's behavior, interventions attempted, and whether the use of a physical restraint was ordered by a practitioner. Interviews with staff members revealed that the charge nurse did not verify the least restrictive method of restraint and did not ensure continuous monitoring of the resident's condition. The staff members involved in the restraint did not consistently apply the restraint and failed to assess other interventions that could address the resident's aggressive behavior. The facility did not take steps to address future potential episodes of imminent danger involving the resident.
Failure to Update Care Plan with Resident's Language and Gender Preferences
Penalty
Summary
The facility failed to update a resident's individualized care plan to reflect personal preferences related to communication and the provision of Activities of Daily Living (ADL) care. Specifically, the care plan did not include the resident's preference for male staff who could speak his native Crow language, which was observed to reduce his agitation and aggression. During an observation, the resident was seen interacting positively with a male staff member who spoke his native language, indicating that this preference was beneficial for his well-being. Interviews with staff members revealed that the resident's preference for male Crow-speaking staff was known and discussed during the facility's daily meetings. However, this preference was not documented in the resident's care plan, which was last revised on 11/18/24. Staff acknowledged the oversight and mentioned that they were working on improving the development of individualized care plans. The omission of this critical information in the care plan led to a deficiency in providing personalized care that could potentially mitigate the resident's aggressive behaviors.
Inadequate Training and Oversight in Restraint Use
Penalty
Summary
The facility failed to ensure that all nursing staff working with a resident who exhibited aggressive behaviors were adequately educated and competent to provide necessary services for the resident's needs, particularly concerning behaviors and the use of restraints. On a specific incident, a charge nurse directed staff to physically restrain a resident who was aggressive towards staff and other residents. The restraint was applied to administer an intramuscular antipsychotic injection, and staff were instructed to continue restraining the resident for an additional 15 minutes to allow the medication to take effect. However, the resident was restrained for a total of one hour without proper nursing oversight or reassessment, as the charge nurse did not reassess or document the resident's condition every 15 minutes during the restraint period. Interviews revealed that the nurse involved was a new graduate who had just passed her nursing boards and was having difficulty managing the situation. Staff members involved in the restraint reported a lack of training on how to restrain a resident, with one staff member indicating it was his first time having physical contact with a resident. The facility's records failed to show documentation of training or education regarding resident care or restraint use for the staff involved. The incident highlighted a deficiency in ensuring that nursing staff had the appropriate competencies to manage residents with aggressive behaviors and the proper use of restraints.
Inadequate Behavioral Health Care Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to accurately reflect the care required for residents with behavioral health needs. This deficiency was identified through interviews and record reviews, revealing that the facility's assessment did not consider the specific needs of residents with aggressive behaviors. Staff members expressed concerns about their ability to manage these behaviors, indicating a lack of appropriate skills and resources. The facility's assessment, dated 12/13/22, claimed to offer services for mental health and behavior management, but staff interviews contradicted this claim, highlighting a gap between documented capabilities and actual practice. During interviews, staff members expressed their inability to care for residents with behavioral health needs adequately. One staff member mentioned that a resident required a one-to-one sitter due to behaviors and was awaiting a psychological evaluation. Another staff member, new to the facility, was unaware of the facility assessment's claims regarding behavioral health care. Additionally, a staff member reported that there were seven residents with aggressive behaviors on the unit, and the CNAs lacked the skills to manage these behaviors effectively. These findings indicate a significant discrepancy between the facility's stated capabilities and the actual care provided to residents with behavioral health needs.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide adequate behavioral health training for staff, which was inconsistent with the needs of the residents. During observations and interviews, it was revealed that staff members were not aware of the specific behaviors or care plan interventions for residents with aggressive behaviors. Staff members expressed uncertainty about how to handle aggressive incidents, with some stating they would seek assistance from the Director of Nursing or other nurses. The lack of training and awareness of care plans was evident among multiple staff members, who were responsible for monitoring residents with known behavioral issues. Resident #2, who has a history of paranoid schizophrenia and aggressive behavior, was observed to have a sitter who was not informed about the resident's past behaviors or trained on how to manage them. The care plan for Resident #2 included non-pharmacologic interventions and monitoring, but staff were unaware of these interventions and did not know the resident's triggers. Similarly, Resident #3 exhibited aggressive behaviors during care activities, and staff reported feeling overwhelmed and untrained to manage such behaviors effectively. The facility's documentation, including care plans and progress notes, indicated a lack of identification of triggers and root causes for the residents' behaviors. Staff interviews highlighted a general feeling of burnout and inadequacy in handling aggressive behaviors, with some staff expressing fear of potential abuse incidents due to the facility's inability to manage such residents. The absence of a structured training program for managing behavioral health needs contributed to the deficiency identified by the surveyors.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent resident abuse involving a physical altercation between a resident and a staff member. The incident involved a resident and her assigned one-on-one Certified Nursing Assistant (CNA) in the doorway to the dining room. The CNA was observed pulling the resident's hands behind her back in an aggressive manner and subsequently pulling the resident to the floor. This altercation was captured on security camera footage, which showed the resident walking into the dining room with her walker, followed by the CNA at a distance. The resident turned and pushed her walker towards the CNA, who then grabbed the resident by her arms, turned her around, and pulled her to the ground, despite other staff members arriving to help de-escalate the situation. Interviews revealed that the staff member involved, identified as easily angered and a bully, was removed from the shift and later terminated. The incident was reported to a staff member who reviewed the security footage and began an investigation.
Failure to Assess Behavioral Outbursts and Provide Required Mental Health Services
Penalty
Summary
The facility failed to assess the root cause or triggers of behavioral outbursts for one resident and did not provide the necessary behavioral health services for another resident as outlined in their PASRR Level II. Resident #2 exhibited a pattern of agitation and aggression, including assaulting another resident and aggressive behavior towards staff. Despite these incidents, no root cause assessments were conducted to identify trends or triggers. Staff interviews revealed that the facility was advised to send the resident to the emergency room during a crisis, but logistical challenges made this difficult. Additionally, attempts to find new placements for the resident were unsuccessful due to her behaviors. Resident #4, who had a history of schizophrenia and required specialized outpatient mental health services, did not have any documentation in their electronic medical record indicating they were receiving or refusing these services. Staff reported ongoing difficulties in coordinating behavioral health services with the only available provider in the area. During the exit conference, it was noted that the facility intended to send the requested behavioral health documentation to the State Survey Agency, but no documentation was received.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days or had documented rationale for extended use, and did not ensure that PRN antipsychotic drugs were renewed only after evaluation by a physician. A resident had PRN orders for Ativan and Olanzapine, both starting on July 1, 2024. The resident received Ativan seven times and Olanzapine twice in July, but there was no physician documentation justifying the continued PRN use of these medications, nor were there stop dates listed. Staff member B indicated that the physician visited the facility once a month and was otherwise available by phone, and that pharmacy reviews to catch stop dates had not been completed for July 2024.
Failure to Update Care Plan for Wound Care and Daily Weights
Penalty
Summary
The facility failed to revise and update the care plan for a resident with a chronic non-pressure ulcer on the right lower extremity. Despite a physician's order to clean the wound and apply specific treatments, the care plan did not include these interventions. Additionally, after the resident was seen in the emergency room for excess fluid retention, the emergency room physician instructed the facility to weigh the resident daily, but this intervention was also not added to the care plan. Interviews with staff revealed that care plan conferences and updates were not completed following the resignation of the previous Director of Nursing, leading to a backlog in care plan updates and meetings.
Failure to Ensure Nurse Competencies for Wound Care
Penalty
Summary
The facility failed to ensure that the nurse competencies and skills were sufficient to provide wound care services for a resident with diabetes and chronic ulcers. The resident's electronic medical record showed an admission diagnosis of diabetes Type 2 with other skin ulcer and a non-pressure chronic ulcer of the right lower leg. The physician's admission order included an order for Gentamicin Sulfate ointment to be applied once a day, but it did not specify which wound was to be treated. The treatment record showed that the wound treatment was not completed on three consecutive days, and there was no documentation explaining why the treatments were not completed. Additionally, the medical records did not show any attempt to contact a medical provider to clarify the wound care orders during this period. A late entry nursing progress note indicated that the orders were hard to read and understand, and it was only on 1/1/24 that the wound care orders were clarified and documented properly. However, the Gentamicin ointment was not available from the pharmacy to be administered on that day. Staff member D confirmed that the admitting physician was not the regular doctor for the resident's wounds and that the wound clinic could not be contacted over the weekend and holiday for order clarification. The deficiency was further highlighted during an interview with staff member D, who acknowledged that the admission orders did not include the complete wound treatment because the admitting physician was not familiar with the resident's wound care needs. The staff member also mentioned that the wound clinic, which had been treating the resident prior to admission, was closed for the weekend and holiday, making it impossible to obtain order clarification until 1/1/24. This delay in obtaining and clarifying wound care orders resulted in the resident not receiving the necessary wound treatments for several days, as documented in the medical records and treatment logs.
Inaccurate PBJ Data Submission for RN and Licensed Nurse Coverage
Penalty
Summary
The facility failed to accurately submit Payroll Based Journal (PBJ) data for Registered Nurse (RN) coverage, specifically eight consecutive hours per day for five days and 24-hour licensed nurse coverage for 25 days in Quarter One of Fiscal Year 2024. The review of the Quarter One report showed no RN hours for specific dates and failed to have licensed nursing coverage 24 hours per day for multiple dates. Employee timecards, however, indicated that RN hours and licensed nurse coverage were present on those dates, suggesting discrepancies in the data submitted to the PBJ system. During interviews, staff members revealed that the data submitted was based on a schedule provided by the Assistant Director of Nursing (ADON) to the business office at the beginning of each month. If changes were made to the schedule during the month, the business office did not receive an updated schedule. Staff member H admitted that she did not use employee timecards to enter data, leading to inaccuracies in the PBJ submissions. Staff member A confirmed that during a Quality Assurance and Performance Improvement (QAPI) meeting, it was identified that licensed staff hours were not correctly submitted to the PBJ, and the facility was working on developing a new process to report actual working hours for licensed staff.
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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