Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beartooth Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to enforce its smoking policy and accident-prevention measures for multiple smokers, including a resident on O2 who used an open-flame lighter near oxygen equipment and smoked in an outdoor area while wearing a nasal cannula and having a portable O2 tank attached to a wheelchair. The outdoor smoking area lacked required signage and staff supervision, and residents reported that smokers went outside unsupervised. Another resident with a history of marijuana-related incidents kept cigarettes and a lighter accessible in her room despite a care plan and smoking safety screen requiring the lighter to be stored at the nurse’s station. Additional smokers and vape users were not consistently identified on the smoking list or addressed in care plans, and one resident was observed rolling cigarettes in his room with multiple lighters present. These conditions led to an Immediate Jeopardy citation under F689 for accidents and hazards.
Lack of Qualified Dietary Oversight: The facility did not employ a certified dietary manager with oversight of the kitchen or a full-time RD to oversee the dietary dept. The dietary manager said he was not currently certified and did not know who the facility RD was. Other staff said the facility did not have a certified dietary manager, one staff member only handled ordering, and her ServSafe certification was being used to meet the requirement even though she was not providing kitchen oversight.
Opened sugar bags were left improperly closed and undated in dry storage, kitchen equipment and surfaces in the dish area and microwave were heavily soiled, and ground beef and sausage were thawing at room temperature on a rack. During breakfast tray assembly, an employee used the same gloves to handle a plate, biscuit, gravy ladle, eggs, diet card, and fruit cup without changing gloves.
The facility failed to provide effective oversight of abuse prevention, infection control, housekeeping, dietary services, and activities. Residents experienced verbal mistreatment, unwanted touching, repeated elopements, missed TB screening tracking for new hires, missed appointments due to transportation issues, dirty rooms, shortages of food and supplies, inadequate dietary oversight, and an activity program that did not meet resident needs. Staff also described late incident reporting, poor communication, and lack of coordination by the administrator and other leaders.
A governing body oversight failure was cited after repeated IJ findings for F689 and related abuse/neglect deficiencies. Staff A did not recognize that a resident was smoking outside with nasal cannula oxygen on and described smokers as independent, while regional leadership said the owners were the governing body but were not directly reviewing QAPI or providing documented oversight. The facility had prior IJ findings involving a serious fall injury and neglect, and the current survey again found IJ related to residents who smoke and use oxygen.
Facility assessment was not accurately completed and did not identify a sampled resident with care needs. The assessment stated that residents needing hemodialysis would be transported out and that residents with elopement risk who could not be safely managed with a Wander Guard system would not be admitted, yet staff could not explain why a known elopement-risk resident was admitted. Staff also reported the assessment listed the wrong governing body names and referenced a Wander Guard system the facility did not have.
QAPI Program Failed to Address Resident Safety and Smoking Concerns: The facility did not maintain an effective QAPI/QAA process or documentation of ongoing quality assurance monitoring. Staff reported monthly QAPI meetings and some PI plans, but the binder was disorganized and there was no evidence of meaningful governing board review. During the survey, one resident eloped multiple times and another resident was observed smoking while on O2 with a lighter in the room; staff were aware of the smoking issue, but the facility had no operational smoking policy and no documented QAPI action for the concern.
Failure to Complete Pre-Employment TB Screening: The facility did not ensure TB screening was completed for new hires as required by its infection prevention and control program, facility policy, and CDC guidance. Staff stated there was no system to track employee TB screening, and record review showed many employees had no documented TB test, while others were tested only after surveyor request or at unverified outside locations.
The facility failed to protect multiple residents from abuse and neglect. A cognitively impaired resident with known boundary and sexual behavior issues repeatedly engaged in inappropriate physical contact with female residents, yet his care plan lacked specific interventions or protections before and after these events, and the facility did not substantiate abuse despite documented behaviors. A staff member verbally abused a resident by directing profane, demeaning language toward the resident, and interviews revealed a pattern of rudeness that made residents feel small. Another resident with a known history of exploitation and leaving prior facilities eloped five times over a short period, each time without staff awareness and once reaching a busy area near an interstate, showing that effective measures to prevent further elopements were not implemented.
The facility failed to submit required investigative findings to the State Survey Agency within five working days for multiple reportable events, including verbal mistreatment in a dining room, allegations of inappropriate touching between residents, and several elopement incidents. Staff responsible for reporting acknowledged that final investigation reports were submitted late, and one staff member cited being reassigned to kitchen duties as a reason for a delay. These actions did not follow facility policies that require the administrator or designee to report investigation results to appropriate agencies within the specified timeframe.
Unsanitary Resident Rooms and Hallway Insects: Surveyors observed two residents’ rooms with dust, crumbs, greasy soil, trash, and other debris around furniture, doors, and bathroom areas, and one resident said housekeeping did not deep clean her room or reliably remove trash. Another resident said housekeeping did not clean under furniture and that the dirty room bothered her and her son. Live insects were also seen crawling in two hallways, and housekeeping logs showed multiple days with no room cleaning or staff reassigned to laundry.
Care plans were not properly updated for a resident who communicated by cell phone, a resident whose representative was not invited or involved in care planning, and two residents with smoking-related needs. Staff observed one resident texting as the main communication method, but the care plan did not direct staff on how to communicate with her. A resident representative said he had never been invited to care plan meetings, and there was no documentation of participation or an explanation why it was not practicable. Two residents who smoked also had incomplete care plans, including missing oxygen and lighter safety interventions for one resident and a missing smoking apron intervention for another.
A facility failed to ensure arbitration agreements were presented for informed, voluntary consent and not treated as routine admission paperwork for 3 residents. Staff said they did not separately review each form or explain what arbitration meant, and family members and a resident stated they signed without understanding the agreement or being told it waived court rights. Records showed signed arbitration agreements in the admission packets, including one resident who said she was foggy at admission and did not recall the form being explained.
A resident repeatedly eloped from the facility without staff knowledge, and the facility failed to conduct thorough investigations into these incidents. Investigation files lacked staff and resident interviews, did not identify root causes, and in one case contained no investigative information beyond chart copies. Staff reported the resident had a history of homelessness, was possibly in a witness protection program, and was allowed to smoke outside unattended due to limited manpower. A staff member who had ideas about how and why the resident eloped was never interviewed, and the staff member responsible for the investigation admitted that a comprehensive review, including staff interviews, was not completed. The resident was consistently found by community members rather than facility staff, and documentation of staff re-education on elopement prevention was incomplete and undated.
Failure to notify a resident representative of changes in condition and treatment. A resident had a fall and was later started on an antibiotic for a UTI, but the record did not show that the POA was notified of either event. The POA stated she had not been called about the fall or the UTI treatment, despite the facility policy requiring notification of the MDS Coordinator, physician, and resident representative when a change in status is identified.
Failure to care plan right-hand ROM decline: A resident was observed with the right hand flexed into the palm and unable to fully open the fist, and later was spoon-fed at breakfast without using the hands to assist. Staff reported the resident had not been able to eat with her hands since returning from the hospital and had declined after a recent hospitalization. The care plan did not identify the ROM limitation or include interventions for ROM, positioning, or therapy evaluation, and there was no documented revision to reflect the change in function.
Activity Program Did Not Meet Resident Interests: Two residents reported boredom and limited choices, saying Bingo was the main activity and weekend options were minimal. One resident stayed in her room reading, while another said she spent much of her time in her room and was not engaged. Staff said the activity dept was new, calendars were preapproved, and the monthly schedule offered only rotating activities with none after 3:00 p.m.
Failure to provide care to maintain ROM: A resident was observed with a right hand fixed in a flexed position, unable to fully open the fist, and required full assistance for meals without using the hands. Staff noted the resident had not been able to eat with her hands since returning from the hospital, and the MDS showed a decline in functional status after hospitalization. The care plan did not identify the right-hand ROM limitation or include interventions for ROM, positioning, or a therapy eval.
Failure to assess and provide services for a resident with moderate depression and difficulty adjusting to the facility. The resident said he felt sad, lonely, cried daily, slept poorly at night, and slept during the day, while also reporting that other residents stared at him and talked about him. Staff acknowledged he was depressed, had no established group of friends, and that the care plan did not direct staff on helping him cope with depression or negative interactions with other residents; the resident was on an antidepressant, but its effectiveness was often charted as N/A.
A resident’s chart did not contain the required admission agreement or other intake paperwork, including billing and resident rights/responsibilities information. Staff said the admission paperwork should have been completed at admission, but it could not be located, and social services documented contacting the resident’s POA/legal guardian about the missing intake packet.
A cognitively impaired, nonverbal resident with a history of wandering experienced an unwitnessed fall resulting in a major injury. Staff failed to perform a thorough assessment, did not document the incident properly, and delayed notifying the DON and transferring the resident to the hospital. The resident required surgery for a hip fracture and lost independent ambulation. Facility policies for fall prevention and post-fall care were not followed.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in significant injury. Staff failed to thoroughly assess the resident, did not use a mechanical lift for transfers, and left the resident in pain and soiled clothing. The incident was not properly documented or reported to the State Survey Agency, and communication among staff was incomplete and inaccurate.
Staff failed to conduct a thorough assessment, pain evaluation, or proper transfer for a resident after an unwitnessed fall with injury. The resident, who was non-verbal and cognitively impaired, was moved without a mechanical lift and later showed increased pain. No pain or fall assessment was documented, and incident documentation was delayed by over four months, contrary to facility policy and professional standards.
The facility did not maintain documentation or demonstrate evidence of an ongoing QAPI program, failed to systematically identify and address adverse events such as falls and infections, and did not submit or investigate reportable incidents as required. Staff interviews and record reviews confirmed the absence of regular care conferences, incomplete documentation, and lack of performance improvement activities.
The QAPI committee did not meet regulatory requirements for membership and participation, as only a few staff members attended meetings and there was no evidence of the Medical Director or designee's involvement. This failure to assemble the required interdisciplinary team and hold proper quarterly meetings had the potential to impact all residents.
The facility did not consistently provide required written notifications of resident transfers and discharges to the local Ombudsman, as mandated by policy. Several residents were transferred to hospitals or discharged, but the responsible staff member failed to send or retain copies of the notifications, and the Ombudsman reported not receiving them for an extended period.
A resident who was not a reliable reporter experienced an unwitnessed fall resulting in a hip fracture that required surgery and hospitalization. Despite clear evidence of serious injury and facility policy requiring immediate reporting, staff did not report the incident to the State Survey Agency or document an investigation. Interviews revealed that the Administrator and other staff were unaware of or did not follow required reporting procedures, and no facility-reported incidents were submitted during the relevant period.
A resident experienced an unwitnessed fall resulting in a fractured hip that required surgery and hospitalization. Facility staff did not initiate or document an abuse or neglect investigation, failed to report the incident to the State Survey Agency, and did not follow internal policies for incident reporting and investigation. Staff interviews revealed a lack of understanding and documentation regarding reporting requirements, and no investigation or interviews were conducted following the event.
A resident who sustained a hip fracture and became non-ambulatory after a fall did not receive a Significant Change MDS assessment as required. Instead, staff completed a Quarterly MDS, despite the resident's increased dependence on staff for mobility and daily care. The responsible staff member acknowledged the oversight and stated that only the RAI manual was used for MDS policy guidance.
A Quarterly MDS assessment for a resident was not submitted within the required timeframe, with the responsible staff member citing workload and additional shift coverage as reasons for the delay. The assessment was completed but submitted 11 days late, contrary to facility policy requiring timely submission of MDS data.
A resident receiving daily insulin injections and oral hypoglycemic medication for type 2 diabetes was not accurately coded for these medications on the MDS assessment. Despite clear documentation in the MAR and physician orders, the MDS sections for injections and hypoglycemic use were marked incorrectly, and the staff member responsible could not explain the omission.
A resident receiving telehealth mental health services for PTSD did not have these services reflected in their comprehensive care plan. Staff confirmed that care plans should address mental health concerns and interventions, but the plan only included medication management and monitoring, omitting the behavioral health services being provided.
The facility did not make grievance forms or the grievance official's contact information readily available, nor did it provide a clear option for residents to file grievances anonymously. Two residents were unaware of how to file a grievance or where to find the necessary forms, and staff confirmed that required postings and receptacle labels had not been maintained.
The facility did not make the most recent certification survey results readily available in common areas after renovations, as confirmed by staff and a resident who was unaware of the survey binder's location.
A resident's room was found to be persistently unclean and hazardous, with an exposed air conditioning unit, soiled bathroom, littered floor, and a full waste bin. Despite facility policies requiring daily housekeeping, the room remained in this condition over several days, and both the resident and family expressed dissatisfaction with the cleanliness and the need to request cleaning services.
Surveyors found that the facility did not develop or implement comprehensive, individualized care plans for four residents with complex needs, including those with communication deficits, immobility, pressure ulcer risk, and diabetes. Care plans lacked measurable, person-centered interventions and did not address key areas such as communication strategies, pressure ulcer prevention, or diabetes management. Staff interviews indicated a reliance on shift reports rather than care plans for guiding resident care.
Staff failed to follow infection prevention and control protocols, including not wearing required PPE during high-contact care, not implementing Enhanced Barrier Precautions, and not maintaining proper hygiene during medication administration. Additionally, laundry staff lacked knowledge of infection control measures and did not use protective gowns when handling soiled clothing.
Two residents experienced unsanitary bathroom conditions, with fecal material observed on toilets over several days and no evidence of cleaning, despite staff claims of daily cleaning and the absence of cleaning logs or policies.
Two residents experienced significant changes in their medical conditions—one with a new suprapubic catheter and another with a new diabetes diagnosis—but their care plans were not updated to reflect these changes. Staff relied on verbal and written shift reports rather than consistently revising care plans, despite facility policy requiring updates after hospitalizations or significant changes.
A staff member crushed and administered a delayed-release medication, Depakote, which is not recommended to be crushed, to a resident in order to facilitate swallowing. The staff member acknowledged this practice, despite facility pharmacy guidance indicating that Depakote should not be crushed, and a physician order allowing crushing only when not contraindicated.
A resident with ALS who was dependent on staff for ADLs was not provided with frequent turning or repositioning, resulting in new skin redness to the coccyx and perineum. The care plan and EHR did not address or document frequent turning, and observations showed the resident remained in the same position for extended periods, requiring her to request assistance via the call button.
A resident with ALS and respiratory concerns did not have physician orders for BiPAP parameters documented in the medical record. Staff were unclear about oxygen delivery settings and the meaning of physician instructions, and the resident's care plan did not address her BiPAP needs or related anxiety.
A resident received PRN diazepam for anxiety and mood on 23 occasions each month over a two-month period, with the order lacking a required 14-day stop date. The medication order remained active without documented evaluation or re-evaluation of the resident's need, and staff were unaware of the missing stop date until it was brought to their attention.
Failure to Enforce Smoking Safety and Oxygen Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement and operationalize its smoking policy and accident-prevention practices for multiple residents who smoked, including those using oxygen and those with a history of unsafe smoking behaviors. Surveyors found that the facility did not maintain an accurate list of residents who smoked, omitting one resident who had a documented smoking safety screen. The facility also failed to identify and address individualized smoking safety risk factors in care plans for several residents, and did not ensure that smoking materials, such as lighters, were secured as required by assessments and care plans. One resident using oxygen was observed engaging in unsafe practices on multiple occasions. In her room, she used a lighter with an open flame to heat craft materials while an oxygen concentrator was present, with no oxygen hazard or no-smoking signage on the door. She was later observed in the designated outdoor smoking area wearing a nasal cannula with a portable oxygen tank attached to her wheelchair while smoking a lit cigarette, and another resident sat nearby also smoking. The resident stated she turned off the oxygen and moved the cannula, but the oxygen tank gauge still showed pressure. Staff interviews revealed that some staff believed it was unsafe for her to have lighters in her room or to go outside with oxygen, yet her smoking safety screen incorrectly documented that she did not use supplemental oxygen and deemed her safe to smoke without supervision. Another resident, identified as a smoker, kept cigarettes and a lighter accessible in her bedside dresser drawer despite a history of marijuana-related concerns documented in progress notes, including reports of her allegedly smoking marijuana on the premises and staff and law enforcement involvement. Her care plan initially identified her as at risk for injury related to smoking and allowed independent smoking, with an intervention later added requiring her lighter to be stored at the nurse’s station. However, during observation, the lighter remained in her room and accessible, contrary to the care plan and smoking safety screen that specified the lighter should be locked at the nurse’s station. Additional residents who smoked or used vapes were not consistently assessed or care planned for smoking or vaping, including one resident listed as a smoker whose record and care plan did not address smoking or vape use, and another resident who reported being independent with smoking and had a smoking safety screen for an electronic cigarette, but whose vape had been found on a heater and removed by staff. A further resident who smoked was not included on the facility’s smoking list despite having a smoking safety screen completed shortly after admission. This resident was observed rolling cigarettes in his room with several lighters and bags of tobacco on his dresser and stated that smoking times were flexible and that smokers outside were not supervised by staff. He also reported that another resident had to wear a smoking apron because she had burned her clothes and believed the apron was a punishment. The facility’s written policies required a designated smoking area with posted signage, prohibition of oxygen use in the smoking area, and maintenance of smoking materials by nursing staff for residents requiring supervision, as well as staff involvement in identifying environmental hazards. Observations showed the outdoor smoking area lacked visible designated smoking and no-oxygen signage, residents smoked there without staff supervision, and oxygen equipment was present in the area, all contrary to the facility’s policies. The surveyors determined that these failures contributed to an Immediate Jeopardy situation related to accidents and hazards, specifically involving the resident using oxygen while smoking. The Immediate Jeopardy was cited at F689 – Accidents and Hazards at a severity and scope level of J before later being reduced in severity after the immediacy was removed.
Lack of Qualified Dietary Oversight
Penalty
Summary
The facility failed to employ a certified dietary manager who provided necessary oversight to the kitchen or a full-time dietician to oversee the dietary department. During interview, the dietary manager said he had been in the position for approximately three months, had received an email showing enrollment in an education course two to three days earlier, and was not currently certified. He also stated that he did not know who the registered dietitian was for the facility. A staff member informed the survey team that the facility did not currently employ a certified dietary manager. Another staff member stated she worked part-time and assisted with nutritional oversight for residents. A different staff member said she only handled ordering and did not provide oversight to the dietary staff or dietary manager. She was told the facility was using her ServSafe Food Protection Manager Certification to meet the certified dietary manager requirement, but she stated she was not aware she was expected to provide kitchen oversight and was not present in the kitchen enough to do so. Documentation requested from the dietary manager's personnel file or resume was not provided before the end of the survey to verify prior work experience, certification, training, or qualifications consistent with regulatory requirements.
Unsanitary food storage, thawing, equipment cleaning, and tray assembly practices
Penalty
Summary
Food was not stored, thawed, handled, and served in accordance with professional standards in the kitchen. During an initial kitchen tour, opened bags of powdered sugar and granulated cane sugar were found in the dry storage area without open dates and not properly closed or covered, and granulated sugar was spilled on the floor beneath the storage rack. On a later kitchen visit, a fan in the dish area had a heavy accumulation of dust, grease, grime, and debris, the floor beneath the dishwasher had a heavy buildup of dark debris and food residue around the drain and plumbing pipes, and the microwave contained dried food splatter and residue on the interior surfaces, turntable, door, and frame. Staff stated these areas had not been cleaned, and the kitchen cleaning log did not show cleaning of the fan or the floor beneath and around the dishwasher. During the same kitchen observations, two commercially packaged tubes of ground beef and sausage were thawing on a metal rack at room temperature in the kitchen rather than in a refrigerator or other approved method. During breakfast tray assembly, a staff member used the same gloved hands to handle a plate, tear a biscuit, pick up a gravy ladle, spoon eggs with a separate utensil, handle a diet card, and place a fruit cup on the tray without changing gloves during the process. The facility policy required proper dry storage, approved thawing methods, and cleaning and sanitizing of food equipment, and the handwashing guidelines required hand hygiene after touching unsanitary items and when changing tasks to prevent cross contamination.
Administrative Oversight Failures Across Abuse Prevention, Infection Control, Housekeeping, Dietary Services, and Activities
Penalty
Summary
The facility failed to provide effective administrative oversight of day-to-day operations related to abuse prevention, infection control, housekeeping, dietary services, and activities. Review of facility-reported incidents showed resident #27 was verbally mistreated by other residents in the dining room, resident #28 reported inappropriate and unwanted touching by another resident, and resident #37 reported inappropriate and unwanted touching by another resident. The facility also reported that resident #46 eloped from the facility on five separate occasions without resident-specific interventions, monitoring, or oversight being put into place to prevent repeated elopements. During interviews, staff member A stated she was responsible for initial abuse and neglect reporting and submission to the electronic abuse reporting system, but did not recall why reports for the incidents involving residents #28 and #37 were submitted late. Staff member A also stated she had instructed staff not to document resident #17's behaviors as sexual behaviors, and to only document them in the electronic medical record and care plan, after two incidents in which resident #17 touched residents #28 and #37 in a sexually inappropriate manner. Staff member B stated the final investigation reports related to resident #46's elopements were submitted late. Staff member A also stated the investigation findings for the incident involving resident #27 were turned in late because she was working as a cook in the kitchen to cover an immediate staffing need. The facility also failed to ensure pre-employment TB screening was tracked and completed for new employees. Staff member A stated she did not know whether TB screening was occurring for newly hired employees, referred to the screenings as the nurses' responsibility, and acknowledged she was ultimately responsible but had not developed a system with the DON or infection control nurse to document, administer, or track the screenings. In addition, resident #30 missed appointments because they were scheduled when the facility did not have a van or driver, and staff member A stated she had forgotten to reschedule once transportation was available. Resident #30 also reported missed appointments and inconsistent room cleaning, while staff described repeated concerns about shortages of food, supplies, and toiletries, a missed resident pickup from an appointment, and a new admission arriving without necessary supplies because the administrator had not communicated it to staff. Observations showed residents #9 and #29 had unclean floors, with heavy stains, garbage, and food debris in their rooms. Both residents stated housekeeping did not move furniture or clean thoroughly. Staff member A stated the facility had experienced census growth but had not made changes to housekeeping staffing to meet the increased need. The facility also lacked adequate oversight of dietary services, as staff member S stated she only did ordering and did not provide oversight to dietary staff or the manager, and she was not aware she was expected to provide such oversight. Staff member A acknowledged the facility was not surprised by resident complaints about activities and stated the activity director had only recently started, while the residents complained that the activities offered did not meet their needs.
Governing Body Failed to Ensure Oversight of QAPI and Safety Practices
Penalty
Summary
The facility's governing body failed to provide necessary oversight for the identification and correction of quality deficient practices involving staff member A and the facility's systems and services. The report states the facility had two consecutive surveys with Immediate Jeopardy findings in the area of F689 - Accidents and Hazards, along with multiple deficiencies directly involving staff member A's failures to take necessary or appropriate action on a concern. The deficiency was tied to the governing body's failure to ensure oversight was in place for management and operation of the facility and for QAPI-related review and monitoring. The prior complaint survey, with an exit date of 9/4/25, resulted in Immediate Jeopardy at a J level for F689 related to a resident who sustained a serious major injury from a fall, and a G-level deficiency for F600 - Abuse and Neglect related to neglect of a resident with a serious major injury. The current recertification survey was the facility's first recertification survey after its initial certification survey with an exit date of 12/5/24. The current survey again identified Immediate Jeopardy in F689 involving residents who smoke and use oxygen, as well as F600 abuse and neglect findings, resulting in second consecutive Immediate Jeopardy findings for the facility. During interviews, staff member A stated she was not aware that resident #12 was outside smoking with her nasal cannula and oxygen on, and said the resident knew not to wear the nasal cannula or use oxygen while smoking. Staff member A also stated resident #12 was not to keep lighters in her room with oxygen equipment and that the residents who smoked were independent smokers, so routine monitoring was not needed as it would be for supervised smokers. Staff member N stated he, along with regional staff members B and C, provided oversight to staff member A and QAPI, but also stated the governing body listed on the facility assessment was the company owners and that the assessment needed revision because the owners were not called in to review QAPI or provide direct administrative oversight. He further stated there was no documentation or signatures of his oversight reviews. Staff member C stated she oversaw the facility as a regional consultant and had been coming in since November to monitor plan of correction audits from the prior survey.
Facility Assessment Not Accurate or Complete
Penalty
Summary
The facility failed to accurately complete its facility assessment and failed to identify one sampled resident, resident #46, in relation to care needs. The assessment completed on 8/1/25 stated that residents requiring hemodialysis would be transported to an outside facility and that individuals who present as an elopement risk and cannot be safely managed with a Wander Guard system would not be admitted. During interview, staff member A said she was not sure whose facility assessment was in the facility folder and noted it might contain the name of a different facility owned by the parent company. Staff member A was unable to explain why the facility admitted a resident known to be an elopement risk when the resident assessment identified that risk before admission. During a separate interview, staff member N said he was the governing body with help from regional nurses, but the facility assessment listed two different male names as the governing body. Staff member N said he assisted in writing and reviewing the facility assessment. He also said he would revise the assessment to identify a siren guard alarm because the facility does not have a Wander Guard system. Staff member N stated the administrator made minor changes the day prior to the interview and that the administrator and DON needed to review and update some clinical areas to correct the facility assessment.
QAPI Program Failed to Address Resident Safety and Smoking Concerns
Penalty
Summary
The facility failed to maintain an effective QAPI program with a plan describing the process for conducting QAPI and QAA activities, and there was no documentation or evidence of an ongoing comprehensive quality assurance program. During a QAPI observation and interview, staff stated the QAPI team met monthly and had begun performance improvement plans for some areas of concern, but no improvement plans had been initiated related to smoking because smoking had not been considered an issue. Staff also stated the QAPI binder was dropped and disorganized, and the administrator said she would have to go through it to find QAPI audits and monitoring records for performance improvement plans. Although staff said the facility had ongoing performance improvement plans for accidents and safety, the only record identified showed a performance improvement plan dated 12/8/25 to prevent a resident from eloping, with vendor audits starting the same day; that resident had already been discharged on 12/7/25. The governing board representative stated he had not documented review of QAPI minutes and there was no evidence he had added information to update or change monitoring processes, although he said regional nurses visited the facility and relayed resident care concerns to the QAPI team. Survey findings from the prior September showed ongoing quality assurance monitoring should have been initiated for resident safety concerns. During the current survey, a resident eloped 5 times in 43 days, and another resident was observed smoking while wearing oxygen, with a lighter in the room and oxygen present. Staff were aware of the smoking concern, but the facility did not have an operational smoking policy and did not implement corrections for the smoking concerns.
Failure to Complete Pre-Employment TB Screening
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring pre-employment TB screening was completed for newly hired employees in accordance with facility policy and CDC guidance. During interview, staff member A stated she did not know whether TB screening was being completed for new hires, said there was no system to track it, and acknowledged she did not know if anyone had received pre-employment TB screening since the facility opened. Staff member E stated pre-employment TB screening had not been performed prior to the survey period and that the facility had not had a system to monitor or track employee TB screening status. Staff member D stated she did not know she was supposed to perform new employee TB tests and had not been given the tools needed for that role. Record review showed a facility document listing 39 employees, with 6 having TB screening completed at unidentified outside locations, 15 receiving TB screening on 2/7/26 after the surveyor requested documentation, and 18 with no indication of TB testing. The facility assessment stated the facility maintained an aggressive infection prevention and control program under the direction of the DON and that policies and procedures were based on CDC guidance. Facility policies titled Employee Tuberculosis Testing and Infection Prevention and Control Program stated that all new staff shall undergo pre-placement TB screening and that direct care staff shall be tested for TB upon hire. CDC guidance reviewed by the surveyor stated all U.S. health care personnel should be screened for TB upon hire, including a risk assessment, symptom evaluation, and TB blood test or TB skin test.
Failure to Prevent Resident‑to‑Resident Sexual Contact, Verbal Abuse, and Repeated Elopements
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and neglect, including inappropriate physical contact between residents, verbal abuse by staff, and repeated elopements. One resident with severe cognitive impairment and a history of boundary issues was documented as inappropriately touching another resident’s bottom and seeking out female residents to touch or kiss, as well as groping himself while looking into female residents’ rooms. Despite this, his care plan did not include documentation or interventions specific to sexual behaviors or lack of physical boundaries, either before or after the incident. A subsequent incident involving the same resident bumping another female resident’s thigh occurred after staff had already noted increased sexual behaviors and disruptive conduct, yet the care plan still lacked protective measures or behavior-specific interventions. Facility investigation notes indicated that both cognitively impaired residents involved could not recall the incidents, and the events were deemed “unable to substantiate,” even as staff acknowledged the resident’s sexual behaviors and instructed him to keep his hands to himself. The deficiency also includes an incident of verbal abuse toward a resident by a staff member. During shift change, a staff member directed profane and demeaning language at a resident, telling the resident to “shut the f k up.” The facility’s investigative report substantiated that this statement was made as alleged, and interviews identified additional reports that the same staff member was rude and made residents feel small. The facility’s own findings characterized the language used toward the resident as verbal abuse, confirming that the resident was not kept free from abusive treatment. Additionally, the facility failed to prevent neglect related to repeated elopements by another resident. Over a 43‑day period, this resident left the facility five times without staff awareness, and each time was found in the community rather than on facility grounds, including once approximately one mile away at a busy stop near an interstate. The resident had been admitted from a sister facility and had a known history of leaving to go to a park where she exchanged sex for drugs and had been exploited for sex and drugs. Despite this history and the repeated elopements, the resident was able to leave the facility multiple times without detection, demonstrating that effective plans and protections to prevent further elopements were not in place.
Failure to Timely Submit Investigation Results for Abuse, Neglect, and Elopement Incidents
Penalty
Summary
The deficiency involves the facility’s failure to submit investigative findings for multiple reportable abuse and neglect incidents to the State Survey Agency within the required five working days. For one resident, an incident report submitted on 10/2/25 documented mistreatment in the dining room through verbal comments from other residents, but the facility did not submit the investigative findings until 10/10/25, one day past the deadline. For another resident, an incident involving reported inappropriate touching by another resident was submitted on 1/3/26, but the investigative findings were not reported until 1/11/26, two days late. A third resident reported inappropriate and unwanted touching by another resident in an incident submitted on 1/25/26, and the facility did not submit the investigative findings until 1/31/26, one day after the deadline. The facility also failed to timely submit final investigation reports for multiple elopement incidents involving another resident. An allegation of neglect related to an elopement on 11/1/25 at 10:20 a.m. was reported on 11/1/25, but the final investigation was not submitted until 11/10/25, three days late. A second elopement for the same resident on 11/1/25 at 5:40 p.m. and a third elopement on 12/3/25 were similarly reported, with final investigations submitted on 11/10/25 and 12/11/25, respectively, each beyond the five-day requirement. Interviews with staff responsible for submitting these reports confirmed that the final investigations for these incidents were submitted late, with one staff member attributing a delay in one case to being reassigned to work in the kitchen. Facility policies on abuse, neglect, and exploitation, and on compliance with reporting allegations, require the administrator or designee to report the results of investigations to appropriate agencies within five working days of the incident.
Unsanitary Resident Rooms and Hallway Insects
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two sampled residents, with observations showing soiled room conditions and inadequate housekeeping services. In resident #29’s room, surveyors observed a yellow and orange spot on the toilet, popcorn and dirt particles around the recliner, a brown sticky greasy-looking substance and crumbs around the dresser legs, a plastic cap under the overbed table, and a paper and open alcohol pad under the recliner. The door frames and hinges were also soiled with dark brown greasy-looking debris. Resident #29 stated her room had never been deep cleaned, that there was only one housekeeper per day, that housekeeping was sometimes pulled to laundry, and that trash and laundry were often left outside the door for pickup. In resident #9’s room, surveyors observed a bandage wrapper and paper on the floor by the sink, dust on the dresser and shelf, crumbs on the floor by the bed and nightstand, a brown dried water stain near the plant stand, and heavy brown-black soiling near the door hinges. Resident #9 stated housekeeping did not come to get trash, did not clean under furniture, and that the dirty room bothered her and her son. Surveyors also observed live insects crawling in the 200-wing hallway and later in the 100-wing hallway. Housekeeping task logs showed multiple days when resident rooms were not cleaned, some shifts were reassigned to laundry, and no resident room deep cleaning was documented.
Care Plans Not Updated for Communication, Family Participation, and Smoking Safety
Penalty
Summary
The facility failed to ensure resident #4’s care plan was reviewed and revised by an interdisciplinary team after a change in condition. During observation and interview, resident #4 was seen texting on a cell phone and staff stated the resident communicated by holding the phone with one hand and typing with one finger, and also had a magnetic board but used the phone most of the time. Staff later stated that care plans were completed and updated by the DON, ADON, infection preventionist, and regional nurses as needed, but the current care plan did not identify or direct staff on how to communicate with resident #4 using the cell phone. The facility also failed to ensure resident #8’s representative was involved in the care planning process or invited to care plan meetings. The resident’s representative stated he had not participated in care planning, had not been invited to a care plan meeting, and had not attended one in person or by phone since the resident’s admission. Staff stated family involvement could occur through meetings, phone calls, or when family members were present in the building, and that a staff member was responsible for inviting residents and representatives to care plan meetings. The record contained no documentation that the representative was invited, attended, signed the care plan, or that participation was not practicable. The facility further failed to keep resident-centered smoking care plans updated for residents #12 and #20. Resident #12 was observed using a lighter with an open flame in her room while crafting, with a faint smell of burning material noted outside the room, and later was observed smoking in the designated smoking area while wearing a nasal cannula connected to a portable oxygen tank. Her smoking safety screen stated she did not use supplemental oxygen and therefore was not assessed to safely remove and store oxygen before smoking, and her care plan did not include interventions addressing oxygen use with smoking or the use of lighters in her room. Resident #20 was observed smoking in the designated area while wearing a smoking apron, and the care plan did not include that apron intervention even though the smoking safety assessment had added it.
Arbitration Agreements Not Properly Explained During Admission
Penalty
Summary
The facility failed to ensure binding arbitration agreements were presented in a manner that allowed informed and voluntary consent, and failed to ensure the agreements were not treated as routine admission paperwork for 3 of 30 sampled residents. Staff member F stated she was only somewhat familiar with the admission packet, did not separately review each document unless asked, and was not familiar with what an arbitration agreement was or why someone would sign one. Staff member A also stated families probably just signed all the forms and did not realize what they were. Staff member J stated she signed the arbitration agreements but was not responsible for explaining them to families. For resident #6, the power of attorney stated she signed the admission documents when the resident was admitted and did not know what an arbitration agreement was because it was not explained to her. She said she signed the forms assuming they were standard admission paperwork and would not want to sign an arbitration agreement for the resident. The facility record included a six-page arbitration agreement dated 11/21/25 with the resident’s typed name on page one and the signatures of the power of attorney and staff member J on page six. For resident #25, the family member who signed the arbitration agreement stated she was not told what an arbitration agreement meant and was only told she could ask questions about the packet. The record showed an arbitration agreement dated 10/30/25 signed by the POA, with the POA and facility representative signatures not dated. For resident #12, the resident stated she signed admission paperwork when she arrived but did not remember signing a binding arbitration agreement or having it explained, and said she was foggy when she got there and had a lot of papers to go through. The arbitration agreement for resident #12, dated 11/20/25 and signed by the resident and staff member J, stated the resident was waiving the right to have disputes decided in a court of law. The facility’s entrance conference documentation also listed no current resident in binding arbitration and identified staff member J as responsible for binding arbitration.
Failure to Thoroughly Investigate and Analyze Repeated Resident Elopements
Penalty
Summary
The facility failed to ensure a thorough investigation of multiple elopements involving resident #46. Facility-reported incidents documented that the resident left the premises without staff knowledge on several occasions over a span of weeks. The investigative files for these events lacked staff and resident interviews, did not identify root causes, and in one case contained no investigative information beyond copies of portions of the chart. The final report for the first elopement stated staff would be re-educated on elopement prevention procedures, but there was no documentation that this education occurred on or near the date of the incident, and the only education roster provided lacked a date, content description, and the name of the presenter. Staff interviews further showed that the investigations were not comprehensive. One staff member reported that the resident had a history of living in a homeless shelter and was potentially in a witness protection program, and that the resident was allowed to be outside smoking unattended because the facility did not have the manpower to supervise smokers. This staff member also stated that the resident’s activity care plan had been changed but could not recall what was needed to prevent further elopements. Another staff member stated she had never been interviewed about the elopements despite having ideas about how and why they occurred and how to prevent them. The staff member responsible for the investigation admitted she did not complete staff interviews and that a comprehensive review was not done, even though the facility later learned the resident had gone under a fence during one elopement rather than over it as initially believed. Across five additional elopements, the resident was identified as missing by community members rather than facility staff, and the investigation files remained incomplete and without timelines or precipitating factors.
Failure to Notify Resident Representative of Changes in Condition and Treatment
Penalty
Summary
The facility failed to notify a resident's representative of changes in resident care and treatment for 1 of 30 sampled residents. Resident #25 had a fall and was found on the floor next to the bed, and the nurse's note stated that day shift staff would be responsible for alerting the resident's power of attorney. However, the remainder of the nursing notes for that day did not show that the power of attorney was notified. In a separate event, resident #25 was started on an antibiotic for a urinary tract infection, but there was no documentation that the power of attorney was contacted about the change in treatment. During interview, the resident's representative stated she had not been called about any falls and had not been notified about the urinary tract infection or the antibiotic. The facility policy titled Care Plan Revisions Upon Status Changes stated that upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative.
Failure to Care Plan Right-Hand ROM Decline
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for resident #1’s limited range of motion of the right hand. During observation on 2/8/26, the resident was seated in a wheelchair with the right hand held in a flexed position, with the fingers curled into the palm. When asked if she could open her fist, she said no, and when she used her left hand to try to pull the fingers open, they did not fully extend. During breakfast observation on 2/9/26, staff member L spoon-fed the resident, and the resident did not use her hands to assist with the meal. Staff member L stated the resident had not been able to eat with her hands since returning from the hospital. Staff member D stated the resident did not have limited range of motion in her right hand upon admission and had declined after a recent hospitalization. Review of the comprehensive care plan, last reviewed on 12/24/25, showed no identification of the right-hand range of motion limitation and no interventions for range of motion, positioning, or therapy evaluation. There was no documented evidence that the care plan was revised to reflect the decline in hand function or to address prevention of further loss of range of motion.
Activity Program Did Not Meet Resident Interests
Penalty
Summary
The facility failed to provide an activity program that met the individual needs and interests of 2 of 30 sampled residents, identified in the report as residents #9 and #29. During observation, three residents were seen in the activity room doing a self-initiated activity, and both residents interviewed described limited activity options and dissatisfaction with the program. Resident #29 said she was tired of Bingo and stayed in her room reading because there was not much to do at the facility. Resident #9 said the only activity was Bingo, that the activity director was new and did not know what to do, and that activities were not what she was interested in. Resident #9 also said there were no activities on weekends except an occasional church group on Sundays, and that she spent a lot of time in her room bored and not engaged in an activity. Staff interviews showed the activity department was newly staffed and calendars were being preapproved through the COTA or a sister facility. One staff member said she oversaw activities and signed off on the monthly calendars, but had not yet seen the February 2026 calendar and was not aware residents were unhappy. Another staff member said she was not surprised there were problems with some activities because the activity director had just started in December. Review of the February 2026 activity calendars showed every Saturday and every other Sunday were listed as resident choice activities for the entire day, there were twelve activities offered on a rotating weekly basis, and no activities were offered after 3:00 p.m. for residents who wanted later participation.
Failure to Address Declining Right-Hand ROM
Penalty
Summary
The facility failed to provide necessary care and services to prevent a decline in range of motion for one resident, whose right hand was observed in a flexed position with the fingers curled into the palm and unable to fully open. During observation, the resident stated she could not open her fist, and when she used her left hand to pull at the fingers, they did not fully extend. The resident was also observed during breakfast requiring full assistance and not using her hands to assist with eating; staff stated she had not been able to eat with her hands since returning from the hospital. Record review showed the resident had been hospitalized and then returned to the facility, and her MDS assessments reflected a decline in functional status after that hospitalization. The discharge MDS showed substantial to maximal assistance for all ADLs, while the later quarterly MDS showed dependence on staff for eating, oral hygiene, toilet hygiene, bathing, dressing, footwear, and personal hygiene. The resident's comprehensive care plan, last reviewed on 12/24/25, did not identify the right-hand range of motion limitation and did not include interventions for range of motion, positioning, or a therapy evaluation.
Failure to Address Resident Depression and Adjustment Difficulties
Penalty
Summary
The facility failed to assess and provide services for a resident who displayed signs of depression and had difficulty adjusting to the facility. During an observation and interview, the resident repeatedly stated he was sad and lonely, said he had been "basically kidnapped" and placed at the facility without knowing he was being left there, and reported missing his daughter and his granddaughter's dog. He said he cried every day, did not sleep well because he was lonely and cried almost every night, and slept during the day to get rest. He also said he went to the dining room but felt bad because a group of residents stared at him and talked about him, and he was observed with tears in his eyes while discussing these concerns. Staff acknowledged the resident slept in the daytime because he was depressed and had good days and bad days. A staff member said she worried about him when his sister did not visit, believed the other residents' behavior could be contributing to his depression, and stated he did not have an established group of friends. Review of the resident's MDS showed a depression score of 10, indicating moderate depression, and he was receiving an antidepressant, though medication effectiveness was documented as N/A 8 of 15 times when it was to be monitored. The care plan, dated 12/8/25, stated he would be referred to behavioral health as needed but did not direct staff on assisting him with depression or negative interactions with other residents. A new depression assessment had not been completed recently, and progress notes later showed he was referred to behavioral health.
Missing Admission Agreement in Resident Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for resident #17 by not having a documented admission agreement in the resident’s medical record. Surveyors reviewed the electronic medical record and found that the resident had an admission date of 11/25/24, but the record lacked admission documentation, including information for billing and resident rights and responsibilities. During interviews, staff member A stated admission paperwork should be completed at the time of admission and that she or staff member K would be responsible for it; staff member A also stated she would have been responsible for resident #17’s admission paperwork. Staff member B stated that resident #17’s admission paperwork could not be located. A social service note dated 2/8/26 documented that a voicemail was left for the resident’s POA/legal guardian explaining that there was no intake packet and that the intake packet needed to be updated, and a blank facility admission agreement stated that completing the admissions agreement is a requirement of Montana law.
Failure to Supervise and Assess Cognitively Impaired Resident After Fall
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a cognitively impaired resident with a history of wandering, resulting in an unwitnessed fall that caused a major injury. The resident, who had Alzheimer's disease and was nonverbal, was found on the floor in the dining room by staff after the fall. Staff manually lifted the resident from the floor to a wheelchair and then to bed, despite the resident showing signs of pain and having a visible hematoma on her head. The nurse on duty did not perform a thorough assessment of the resident's lower extremities and did not complete a pain assessment or document the incident properly in the medical record. Communication among staff was incomplete and inconsistent. The night shift nurse did not immediately communicate all symptoms, including the resident's hip pain, to the DON, which delayed the decision to send the resident to the hospital. The resident remained in the facility overnight, and only after the day shift nurse assessed her condition and noted significant pain and a deformity of the hip was EMS called and the resident transferred to the hospital. The delay in transfer resulted in the resident requiring hospitalization and surgery for a hip fracture, and she lost her ability to ambulate independently. The facility's policies and procedures for fall prevention, post-fall assessment, and notification of changes were not followed. Required documentation, such as a complete neurological assessment and pain evaluation, was missing or incomplete. The care plan for the resident, which identified her as a high fall risk due to wandering and cognitive impairment, was not adequately implemented to prevent the accident or ensure timely and appropriate response after the fall.
Failure to Recognize, Assess, and Report Resident Neglect After Major Fall
Penalty
Summary
The facility failed to recognize and protect a resident's right to be free from neglect following a major injury sustained from an unwitnessed fall. The resident involved had severe cognitive impairment and was non-verbal, making her an unreliable reporter of the event. After the fall, staff did not thoroughly assess the resident, particularly neglecting to assess her lower extremities despite her showing signs of pain. The staff manually lifted and transferred the resident without using a mechanical lift, contrary to facility policy, and failed to document the incident accurately in the medical record. The resident was left in pain and in soiled clothing until the following shift, when a more thorough assessment revealed a significant injury requiring hospitalization and surgery. Multiple staff interviews revealed confusion and lack of adherence to facility protocols regarding post-fall assessment, documentation, and reporting. The nurse on duty did not complete a full assessment or pain evaluation, and failed to document the incident properly after striking out the initial note. Communication among staff was incomplete, with inaccurate information relayed to the resident's family and other staff members. The decision not to send the resident to the hospital was made without a thorough assessment, and staff expressed discomfort with this decision but did not escalate the issue appropriately. The facility also neglected to report the unwitnessed fall with significant injury to the State Survey Agency, as required by both facility policy and federal regulations. The administrator, who also served as the Abuse Prevention Coordinator and Grievance Officer, was unaware of the need to report such incidents and had not submitted any facility-reported incidents in the previous six months. Education on post-fall assessment and reporting was not provided to staff until several months after the incident, further indicating a lack of timely response to the deficiency.
Failure to Perform Post-Fall Assessment and Documentation
Penalty
Summary
Facility staff failed to perform a thorough head-to-toe assessment, pain assessment, or appropriate transfer for a resident following an unwitnessed fall with injury. After being notified of the fall, staff members found the resident lying on the floor in the dining room. The staff picked up the resident and placed her in a wheelchair without using a mechanical lift, despite the resident being non-verbal, cognitively impaired, and later showing signs of pain. The staff then transferred the resident to bed, where she exhibited further signs of pain when her clothing was removed. Staff communicated concerns to each other, but the nurse on duty did not complete a full assessment of the resident's lower extremities, did not document a pain assessment, and did not properly document the incident in the medical record at the time of the event. Review of the resident's records showed no documentation of a pain assessment or fall assessment following the incident, and a late entry note was made 140 days after the fall. Facility policies required comprehensive assessments and care in accordance with professional standards, including assessment after any fall. The failure to follow these protocols resulted in an increase in the resident's signs and symptoms of pain due to a hip fracture sustained during the fall.
Failure to Implement and Document QAPI Program and Event Reporting
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of an ongoing QAPI program that meets regulatory requirements. Staff interviews revealed that there was no QAPI plan in place at the time of the survey, and staff were still in the process of implementing one. Data collection was reportedly occurring through risk management, chart review, and infection prevention binders, but there was a lack of systematic identification, reporting, investigation, analysis, and prevention of adverse events. Staff also indicated that regular care conferences with residents or their representatives were not being held, which limited the gathering and presentation of feedback to the QAPI committee for identifying quality-of-care concerns. Review of facility documents showed that while some QAPI meetings were held and incidents such as falls and urinary tract infections were noted, there was no documentation of tracking, root cause analysis, or performance improvement projects (PIPs) being initiated when indicated. Additionally, the facility had not submitted any facility-reported incidents to the State Survey Agency and could not provide completed investigations for any reportable events. The administrator, who was also serving in multiple roles, acknowledged not documenting incidents or investigations and was unaware of issues requiring reporting. The QAPI program and performance plans did not show active identification or correction of concerns related to event reporting or follow-up.
QAPI Committee Lacked Required Membership and Participation
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) group had the required members and met at least quarterly, as mandated by policy. Interviews with staff revealed that only a limited number of staff members, specifically staff member A, staff member B, and occasionally staff member G, attended the QAPI meetings. Staff member G, who was only onsite once a month, did not attend meetings in person and was only informed of the meeting outcomes after the fact via phone call. There was no documentation to confirm that staff member C attended any meetings by phone, and staff member A acknowledged that additional required members had not been invited to participate in the QAPI meetings. Review of QAPI meeting minutes and attendance sheets confirmed that the required interdisciplinary team composition was not met, with only a few staff members present and no evidence of the Medical Director or designee's participation. The facility's own QAPI policy specified that the committee must include the Director of Nursing Services, the Medical Director or designee, and at least three other staff members, including the administrator. The lack of appropriate committee membership and participation had the potential to affect all residents receiving care in the facility.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide routine written notifications of resident transfers and discharges, including required information to the local Ombudsman, for four of twelve sampled residents. Specifically, documentation showed that several residents were transferred to hospitals or discharged due to death, but the required notices were not sent to the Ombudsman as mandated. Interviews revealed that the staff member responsible for sending these notifications did not consistently provide them, either by email or mail, and did not maintain copies of the notices. The Social Services Director or designee was expected to send these notifications, but this process was not followed for several months. Facility policy required that notices of transfer or discharge, including emergency transfers, be sent to the Ombudsman as soon as practicable and that evidence of such notifications be maintained. However, the Ombudsman reported not receiving these notices for months, and the staff member acknowledged not having sent or retained copies of the required documentation. A retrospective list of transfers and discharges was eventually provided, but it did not demonstrate timely or routine notification as required by policy.
Failure to Report and Investigate Serious Fall Resulting in Hip Fracture
Penalty
Summary
The facility failed to implement and uphold its policies and procedures for reporting an unwitnessed fall involving a resident who was not a reliable reporter. The resident sustained a hip fracture, required surgery, and was hospitalized as a result of the fall. Despite the severity of the injury and the resident's unreliable reporting, the incident was not reported to the State Survey Agency as required. Documentation showed that staff were aware of the fall and the resulting injuries, but the event was not identified as neglect of care or reported as a facility-reported incident. Interviews with staff revealed that the Administrator, who also served as the Social Services Designee, Business Office Manager, Grievance Officer, and Abuse Prevention Coordinator, was unaware of quality-of-care concerns that would require reporting and investigating as facility-reported incidents. The Administrator admitted to not documenting incidents consistently and stated that no facility-reported incidents had been submitted to the State Survey Agency within the last six months, including the event involving the resident's fall and hip fracture. Another staff member confirmed that no reportable incidents had been submitted and described consulting with another staff member, who advised against reporting the event. Review of the resident's nursing progress notes indicated that after the fall, the resident exhibited significant injuries, including a large hematoma, a skin tear, and severe pain in the hip area. The initial response included canceling EMT transport and observing the resident overnight, with a portable X-ray ordered for the following morning. The next day, the resident was found in pain with a suspected broken hip, and EMS was called. The facility's policy required immediate reporting of alleged violations involving serious bodily injury, but no such report was made, and no investigation documentation was provided.
Failure to Investigate and Report Unwitnessed Fall Resulting in Major Injury
Penalty
Summary
The facility failed to initiate an abuse or neglect investigation after a resident experienced an unwitnessed fall that resulted in a major injury, specifically a fractured hip requiring surgery and hospitalization. Despite the severity of the incident, there was no documentation of a facility-reported incident, no investigation was completed, and the event was not reported to the State Survey Agency. Staff interviews revealed a lack of awareness and understanding of reporting requirements, with staff relying on corporate direction to determine whether to report and investigate such incidents. The facility also lacked prepared reports or tracking systems for monitoring incidents over time. Review of the resident's medical records indicated that the resident was found in pain with a broken hip and urine-soaked clothing, and was subsequently hospitalized and treated for additional complications, including blood clots. The facility's own policy required written procedures for reporting and investigating abuse or neglect, including analyzing occurrences and reporting results to government agencies. However, the facility did not follow these procedures, as no investigation or interviews were conducted, and no documentation was submitted for review. Staff admitted to not documenting or investigating unless instructed by corporate, and there was no evidence of compliance with the facility's abuse and neglect policy.
Failure to Complete Significant Change MDS After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who experienced a notable decline in condition following a fall and subsequent hip fracture. After the resident fell and sustained a hip fracture, she underwent surgery and returned from the hospital in a non-ambulatory state. Despite this significant change in her mobility and care needs, the staff member responsible for MDS assessments completed a Quarterly MDS instead of a Significant Change MDS, as required by the Resident Assessment Instrument (RAI) guidelines. The staff member acknowledged during an interview that a Significant Change MDS should have been completed and that she would refer to the RAI guidelines in the future to determine the appropriate assessment. Record review showed that prior to the fall, the resident was independent with ambulation and required only supervision or substantial assistance for other activities of daily living. After the incident, the resident became dependent on staff for transferring, toileting, bathing, dressing, and personal hygiene, and was coded for wheelchair use. The facility's policy for MDS assessments is based solely on the RAI manual, with no additional internal policies in place. The failure to complete the required Significant Change MDS assessment meant that the resident's substantial decline in function was not formally identified through the MDS process.
Late Submission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to submit a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. The assessment, with an Assessment Reference Date (ARD) of 7/11/2025, was completed on 7/25/2025 but was not submitted and accepted until 8/19/2025, which was 11 days past the required submission date. During an interview, the staff member responsible for completing the MDS assessments acknowledged that some assessments were late due to being overburdened with responsibilities, including covering additional shifts on the floor. Review of the facility's policy confirmed the requirement to utilize the current version of the RAI (MDS 3.0) and follow the instructions in the RAI Manual.
Failure to Accurately Code Insulin and Hypoglycemic Medication on MDS Assessment
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Set (MDS) assessment for one resident. Specifically, the resident's Quarterly MDS did not reflect the administration of insulin or other hypoglycemic medications during the 7-day look-back period, despite documentation in the Medication Administration Record and physician orders indicating that the resident received daily insulin injections and oral metformin for type 2 diabetes mellitus. The relevant MDS sections (N0300, N0350, and N0410) were either marked as zero or 'No' for injections and hypoglycemic medication use, which was inconsistent with the resident's actual medication regimen. Interview with the staff member responsible for completing the MDS assessments revealed uncertainty regarding why insulin or hypoglycemic medications were not marked for this resident. The facility's policy required the use of the current RAI (MDS 3.0) and accurate inclusion of medications as per the RAI Manual, but this was not followed in this instance. The deficiency was identified through review of the resident's records and staff interview.
Care Plan Lacked Inclusion of Behavioral Health Services
Penalty
Summary
The facility failed to revise a comprehensive care plan to include behavioral health services for one resident who was receiving mental health care via telehealth. Staff interviews confirmed that care plans should address mental health concerns, including both pharmacological and non-pharmacological interventions, as well as any triggers and pertinent behavioral health information. Record review showed that the resident's care plan, which identified a mood problem related to PTSD, included medication administration and monitoring but did not reflect the ongoing telehealth services provided by a mental health professional.
Failure to Provide Accessible Grievance Process and Information
Penalty
Summary
The facility failed to develop and implement a grievance policy that included the name and contact information for the grievance official, did not provide residents with readily available grievance forms, and did not ensure residents had the option to file grievances anonymously. During a walkthrough of the facility's common areas, surveyors observed that no grievance forms were accessible to residents, there was no posting of the grievance official's contact information, and no secure receptacle was identified for anonymous grievance submission. Staff confirmed that grievance forms were kept in an office rather than in a public area, and that previous postings and receptacle labels had been removed by a resident and not replaced. Interviews with two residents revealed that they were unaware of how to file a grievance, where to find grievance forms, or the existence of a secure receptacle for anonymous submissions. One resident reported that concerns were typically relayed to staff through direct conversation or via a family member, rather than through a formal grievance process. Review of the facility's grievance form and policy showed that required information, such as the grievance official's contact details, was missing from the form, and the policy, while outlining requirements, was not being followed in practice.
Failure to Post Certification Survey Results in Accessible Area
Penalty
Summary
The facility failed to post the results of the most recent certification survey in an area that was easily accessible to residents, family members, and residents' legal representatives. During an observation, no binder containing the survey results was found in the common areas. Staff confirmed that the survey information had been removed during recent renovations and had not been reposted afterward. Additionally, a resident interviewed was not aware of the location of the binder containing the most recent survey results.
Failure to Maintain Clean and Hazard-Free Resident Room
Penalty
Summary
A deficiency was identified when a resident's room was found to be unclean and hazardous over multiple days. Observations revealed that the air conditioning unit in the room had its front panel removed, exposing internal components and an electrical wire, with a heavy accumulation of dust and grime indicating a lack of maintenance. The resident's bathroom toilet was soiled with urine and feces both inside and outside the bowl, and the floor was littered with tissue paper, medication cups, a plastic cup, scraps of paper, and dried brown spots from a spill. The waste bin was full, and the room had not been cleaned for an extended period, as confirmed by the resident, who stated she had to request housekeeping services and was dissatisfied with the cleanliness. Family members also expressed concern about the facility's cleanliness, describing it as atrocious and stating it was not appropriate to have to ask staff to clean the room. Staff interviews indicated that rooms were supposed to be cleaned daily, including sweeping, mopping, and cleaning of bathrooms and surfaces. However, repeated observations over consecutive days showed the resident's room remained in the same unclean condition, with no evidence of housekeeping intervention. Facility policy and the standard admission agreement both required daily housekeeping and routine cleaning to maintain a safe and sanitary environment, but these standards were not met in this instance.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement comprehensive, resident-centered care plans that addressed the physical and psychosocial needs of four residents. For a resident with a traumatic brain injury and communication difficulties, the care plan did not include a focus area or interventions for communication deficits, nor did it provide guidance for staff on how to communicate effectively with the resident. Another resident with multiple sclerosis and limited mobility had a care plan that lacked measurable, person-centered interventions for the prevention and management of pressure ulcers and dehydration, despite being at risk due to immobility and medication side effects. A third resident, who was paraplegic and had a history of pressure ulcers, did not have a care plan that included specific, measurable interventions for pressure ulcer prevention, and staff failed to follow up on the resident's requests for necessary equipment to assist with repositioning. Additionally, a resident with Type 2 diabetes and unspecified complications did not have a care plan addressing diabetes management, monitoring, or related complications. Staff interviews revealed reliance on shift reports rather than care plans for resident care information, and the staff member responsible for care plans did not ensure comprehensive, individualized plans were in place as required by facility policy.
Failure to Implement and Adhere to Infection Prevention and Control Practices
Penalty
Summary
Staff failed to adhere to proper infection prevention and control practices in several areas of the facility. In the laundry department, a staff member was unable to explain whether the washing machine killed pathogens by heat or chemicals and did not wear a protective gown when handling residents' clothing, contrary to infection control principles outlined in facility policy. The Housekeeping/Laundry Competency Checklist required review of correct infection control principles, but staff demonstrated a lack of knowledge and compliance. Enhanced Barrier Precautions (EBP) were not consistently implemented or followed for residents requiring such measures. Staff were observed performing high-contact care activities, such as PEG tube flushes and catheter care, without wearing required gowns or gloves. There was also a lack of EBP signage and supplies in resident rooms where these precautions were indicated. Interviews revealed that some staff were unfamiliar with EBP protocols and that training on these precautions was only being conducted after deficiencies were identified. During medication administration, a nurse placed medications on an uncleaned dresser surface without a protective barrier and failed to perform hand hygiene before donning gloves to administer an injection. Facility policy required staff to follow infection control procedures, including handwashing and use of barriers, during medication administration. These lapses in infection control practices were observed directly and confirmed through staff interviews and review of facility policies.
Failure to Maintain Clean and Sanitary Resident Bathrooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents, as evidenced by repeated observations of soiled toilets in their rooms over multiple days. For one resident, brown specks, appearing to be feces, were observed on the front part of the toilet bowl on three consecutive days, with no indication that the toilet had been cleaned during that period. The resident's family member also reported that the toilet was sometimes dirty during visits. Staff interviews confirmed that cleaning was supposed to occur daily, but there was no documentation or cleaning log to verify this. Another resident reported that the facility did not clean the bathrooms enough, and surveyors observed smeared fecal material on the toilet seat and inside the toilet bowl over a span of three days, with no change in the condition of the toilet. Despite being notified by the surveyor, staff did not address the issue, and the resident confirmed that the bathroom had not been cleaned. Staff interviews revealed that there was no specific cleaning log or policy in place, and the facility was unable to provide housekeeping cleaning logs or policies when requested.
Failure to Update Care Plans After Significant Changes in Resident Condition
Penalty
Summary
The facility failed to update care plans for two residents following significant changes in their medical conditions. One resident, who previously had an indwelling catheter, was transferred to the hospital for a suprapubic catheter insertion and returned the same day. Although physician orders were updated to reflect the new catheter and required dressing changes, the resident's care plan was not revised to include this information. Staff interviews revealed that the responsibility for updating care plans fell to a single staff member, who acknowledged that not all care plans had been updated following hospital discharges. Another resident returned from the hospital with a new diagnosis of diabetes, but the care plan did not reflect this change, lacking any focus area, goals, interventions, or monitoring related to diabetes management. Staff interviews indicated that information about changes in resident care was primarily communicated verbally or through shift reports, rather than through updated care plans. The facility's policy required the interdisciplinary team to review and update care plans after significant changes or hospital readmissions, but this was not consistently followed.
Delayed-Release Medication Inappropriately Crushed During Administration
Penalty
Summary
Staff member F failed to adhere to professional standards of practice by crushing a delayed-release medication, Depakote (Divalproex Sodium), which is not recommended to be crushed, for one resident during medication administration. During observation, staff member F removed metformin and Depakote from their packaging and crushed both medications before administering them in pudding to the resident. Staff member F acknowledged that Depakote was routinely crushed to aid the resident in swallowing, despite stating she typically did not crush delayed or extended-release medications. Facility pharmacy documentation specifically listed Depakote as a medication that should not be crushed, as this can alter the drug's intended mechanism. The resident's physician order allowed for medications to be crushed unless otherwise specified or contraindicated, but did not override the contraindication for Depakote.
Failure to Provide Frequent Repositioning for Dependent Resident with ALS
Penalty
Summary
A deficiency was identified when a resident with Amyotrophic Lateral Sclerosis (ALS), who was dependent on staff for activities of daily living, was not provided with adequate assistance for frequent turning and repositioning to prevent skin breakdown. The resident's electronic health record (EHR) and baseline care plan indicated a need for substantial assistance by staff for turning and repositioning, as well as total or substantial assistance for other ADLs. Despite this, there was no documentation of frequent turning or repositioning in the EHR, and no physician's order or care plan intervention specifically addressing the need for frequent turning to prevent skin breakdown. Observations and interviews revealed that the resident developed new redness to the coccyx and perineum, and was consistently found in the same position on a pillow in her recliner over multiple days. The resident reported that staff did not routinely reposition her and that she had to use the call button every two to three hours to request assistance. Staff confirmed the presence of blanchable redness, and the pillow used for positioning was not adjusted to relieve pressure. The resident stated she never refused repositioning, although she experienced anxiety during the process.
Failure to Maintain Physician Orders for BiPAP Parameters
Penalty
Summary
The facility failed to ensure that physician orders for BiPAP parameters were in place for a resident with respiratory concerns and ALS. During interviews and observations, the resident expressed uncertainty about whether oxygen was being bled into her BiPAP, and no oxygen tank was found in her room. Staff confirmed that the BiPAP machine did not have oxygen bled into the system and were unable to locate the oxygen parameter order in the resident's records. Review of the electronic health record revealed no physician's order for the BiPAP parameters, which should include oxygen delivery (FiO2), EPAP, IPAP, and respiration rate. Further review of a physician's order from the resident's clinic indicated specific instructions for oxygen therapy and BiPAP use, but staff demonstrated confusion regarding the meaning of 'hs' in the order and whether the parameters needed to be entered into the electronic record. The resident's baseline care plan did not document the BiPAP parameters or address her frequent anxiety and air hunger related to her ALS diagnosis.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days as required by federal regulations. A resident was prescribed diazepam 5mg to be taken every eight hours as needed, beginning on 10/2/24, without a stop date indicated in the physician's order. Medication administration records showed that the resident received PRN diazepam on 23 occasions in both October and November 2024, and the order remained active as of 12/4/24. There was no documentation in the resident's medical record of an initial evaluation or any re-evaluation of the ongoing need for PRN diazepam during this period. Staff interviewed were unaware of the missing stop date and only planned to address it after the issue was identified during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 30 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurel Health & Rehabilitation Center | 23.8 mi | ★★★★★ | 30 | 0 |
| St John's Lutheran Home | 32.8 mi | ★★★★★ | 7 | 0 |
| Aspen Meadows Health And Rehabilitation Center | 33.9 mi | ★★★★★ | 23 | 0 |
| Skyline Heights Nursing And Rehabilitation | 34.4 mi | ★★★★★ | 22 | 1 |
| Yellowstone River Nursing And Rehabilitation | 34.5 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.