Benefis Senior Services - Eastview
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Falls, Montana.
- Location
- 2621 15th Ave S, Great Falls, Montana 59405
- CMS Provider Number
- 275012
- Inspections on file
- 21
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Benefis Senior Services - Eastview during CMS and state inspections, most recent first.
A resident who depends on staff for ADLs did not receive a shower at their preferred time, resulting in frustration and a missed meal. Staff failed to follow the care plan specifying morning showers and timely assistance, with delayed call light responses and poor communication about shower assignments contributing to the deficiency.
A resident experienced verbal abuse from a volunteer during a bingo activity, where the volunteer made demeaning comments about the resident's bathroom needs in front of others, leading to the resident feeling sadness and withdrawal. Multiple staff and residents observed the inappropriate behavior, which caused embarrassment and discomfort.
A cognitively impaired, non-verbal resident with a femur fracture was not promptly assessed or investigated after staff noticed her leg appeared abnormal for an extended period. The injury, which was already partially healed when discovered, was not reported or addressed until the resident showed signs of pain. Medical staff questioned the proposed cause of injury, and the facility did not conduct a thorough investigation or consider the possibility of abuse or neglect, despite the resident's vulnerability.
A resident with cognitive impairment and total dependence on staff was found to have a partially healed fracture, but the facility's investigation was incomplete, involving limited staff interviews, no expansion of the investigation timeframe, and no evidence of actions to protect other residents or comprehensive documentation as required by policy.
A resident did not receive repositioning and toileting care every two hours as directed by the care plan, with documentation and staff interviews confirming that these interventions were performed inconsistently and less frequently than required. Staff demonstrated inconsistent knowledge of care plan requirements, and facility records showed significant gaps in both repositioning and check-and-change activities.
A resident with dementia exhibited increased behaviors such as scratching, pinching, and yelling, but staff did not consistently assess or address pain as a possible cause. Despite behavior monitoring and a care plan directing pain assessment, documentation showed few pain assessments and no evidence that pain was evaluated during most behavioral incidents. The resident's records also indicated no PRN pain medication was offered or given during this period.
Surveyors found that clean linens were handled improperly, including being dragged on dirty floors, placed back with clean items after falling, and folded without hand hygiene. Laundry carts containing clean items were left uncovered in various areas, contrary to facility policy. Staff acknowledged lapses in infection control and lack of regular observation in the laundry department.
The facility did not consistently review or update care plans to reflect the individual activity preferences of several residents. Observations and interviews showed that some residents were left without engagement or had their interests overlooked, and staff were not always aware of the need to document or act on these preferences as required by facility policy.
Multiple residents were left without meaningful activities, with some sitting idle in common areas or their rooms despite scheduled events. Staff frequently canceled or failed to offer activities due to being reassigned to other duties, and resident preferences were not consistently assessed or incorporated into care plans. Documentation showed that several residents had little to no participation in activities, and some attended group activities more often than preferred, contrary to their documented interests.
The facility did not ensure that residents had access to appropriate fluids or received adequate meal assistance, resulting in one resident receiving unthickened fluids instead of prescribed thickened liquids and another experiencing significant weight loss and dehydration. Staff were unaware of which residents were at risk of dehydration, and inconsistent practices regarding fluid availability and meal support were observed.
Several residents did not have access to functioning call lights in their rooms or bathrooms, with some unable to reach the call light, others not having one present, and some staff relying on periodic rounding instead of providing call lights. Facility policy requires accessible and working call systems, but these were not consistently available, preventing residents from contacting staff for assistance.
A resident's code status in the EHR was not updated from Full Code to DNR after their POLST form was changed to indicate No CPR. Staff interviews revealed a lack of a clear process for updating code status in the EHR, and the facility's policy requiring documentation of advanced directives in the medical record was not followed.
A resident's personal property, including a blanket of significant religious and personal value, went missing after being sent to laundry and was not returned. The resident and family reported the loss to staff multiple times, but staff were unclear about the process for locating or replacing missing items, and the facility did not maintain a list of missing items as required by policy. Not all personal belongings were inventoried at admission, and there was no documentation of efforts to resolve the loss.
A resident with dementia, impaired cognition, anxiety, frequent pain, and behavioral symptoms was admitted without a baseline care plan being developed within 48 hours, as required by facility policy. The care plan was not initiated until eight days after admission, and staff were unaware of the delay or its cause.
A resident with advanced dementia was repeatedly observed in unsafe situations, such as entering other residents' rooms, leaning forward in her wheelchair close to falling, and attempting to pick up objects from the floor without staff intervention. Despite a care plan outlining the need for redirection, behavioral interventions, and diversional activities, staff did not consistently implement these measures, resulting in inadequate supervision and failure to meet the resident's documented needs.
A resident with a history of alcohol use disorder and recent ingestion of hand sanitizer was able to access hand sanitizer bottles and other hazardous liquids left unattended on medication carts, at the nursing station, and in open cabinets. Staff were aware of the resident's behavior but did not consistently secure these substances, and there was no specific policy in place to prevent resident access to hazardous chemicals.
Two residents with significant behavioral and psychosocial needs did not receive necessary behavioral health care and services. One resident with advanced dementia was observed wandering, crying, and nearly falling, while another displayed frequent aggression and inappropriate behaviors. Staff and social services did not actively address these issues, and there was no documentation of behavioral health assessments or interventions, despite ongoing incidents.
A resident with a history of depression, schizophrenia, and bipolar disorder was identified as needing cognitive rehabilitation with a speech therapist following a psychosocial evaluation. Despite this recommendation, no referral for speech therapy was made due to confusion between facility staff and an outside provider regarding responsibility, resulting in a significant delay in the resident receiving the recommended therapy.
A facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and unmet care needs for several residents. One resident experienced back pain from lying in bed too long, while another had to wait until late morning to be assisted out of bed. Staff interviews revealed common short-staffing issues, impacting timely care and morning routines. The facility's call light policy was not met, with records showing prolonged wait times. Staffing challenges were linked to hiring difficulties, high turnover, and scheduling issues.
A facility failed to provide timely ADL care for three residents due to staffing shortages, leading to potential health risks. One resident experienced back pain from prolonged bed rest, another had delayed assistance affecting ulcer healing, and a third faced incontinence issues and infrequent showers. Staff confirmed that inadequate staffing ratios hindered timely care delivery.
The facility failed to individualize interventions for dementia residents, did not assess the effectiveness of wanderguards, and did not follow protocol for obtaining consent. Two residents eloped due to inadequate monitoring and ineffective use of wanderguards. Staff were unaware of wanderguard placements, and assessments were not conducted to ensure their functionality.
The facility failed to address the behavioral health needs of two residents involved in an altercation. One resident, with developmental delay, did not have an updated PASARR Level 1 or care plan interventions specific to his condition. The other resident, with multiple mental health diagnoses, also lacked updated care plan interventions. Neither resident was followed by social services or behavioral health services, and communication with family members was inadequate.
Failure to Honor Resident's Shower Preference and Timely Assistance
Penalty
Summary
A dependent resident's right to self-determination and preference for shower timing was not honored when staff failed to provide a shower as scheduled and requested. The resident, who relies on staff for assistance with activities of daily living (ADLs), typically receives showers before breakfast and prefers to be up by 8:00 a.m. On the day of the incident, the resident's shower was delayed, and he was left in bed past his preferred time. Documentation shows that the resident's call light was activated twice that morning, with response times of 47 and 43 minutes, indicating significant delays in staff response. The resident expressed frustration, feeling trapped and missing breakfast due to the delay in receiving his shower. Interviews with staff revealed confusion and lack of communication regarding shower assignments. One staff member admitted to not providing the shower, expecting another staff member to handle it upon their later arrival, while the incoming staff was not informed of the assignment until after their shift began. The resident's care plan clearly documented his preference for morning showers and being up by 8:00 a.m., but these preferences were not followed. Facility records also indicated that not all residents' bathing preferences were documented, and staff acknowledged challenges in accommodating resident preferences due to workload and communication issues.
Verbal Abuse of Resident by Volunteer During Activity
Penalty
Summary
A deficiency occurred when a resident was subjected to verbal abuse by a volunteer during a bingo activity. The resident reported that the volunteer spoke to her in a demeaning manner, repeatedly telling her to go to the bathroom even when she did not need to, and used language that made her feel uncomfortable. Written statements from staff and other residents corroborated that the volunteer made inappropriate comments, such as referencing the resident's need to use the bathroom in front of others and making remarks about cleaning up after her. These actions led the resident to feel sadness and withdrawal, particularly in the presence of the volunteer. Multiple staff and resident statements indicated that the volunteer's behavior was observed by others, with reports of the volunteer being demanding, rude, and causing embarrassment to residents. The affected resident was noted to carry a towel to sit on as an act of shame, further highlighting the impact of the verbal abuse. The facility was made aware of the incident and initiated an investigation after being informed by staff and residents.
Failure to Timely Identify and Investigate Major Injury of Unknown Origin
Penalty
Summary
The facility failed to identify and investigate a major injury of unknown origin in a timely manner for a cognitively impaired, non-verbal, and non-ambulatory resident. The resident was found to have a femur fracture that was already partially healed by the time it was discovered, indicating the injury had occurred at least two to three weeks prior. Staff had noticed the resident's leg appeared awkward for some time but did not report or address the concern, assuming it was normal for the resident. When the resident eventually cried out during care, nursing staff were called to assess, and the resident was sent to the emergency room, where the fracture was confirmed. Multiple staff interviews revealed that there was uncertainty about the cause of the fracture, with some staff doubting the explanation that the injury was caused by the resident's foot being caught under a heater. The treating surgeon and other medical professionals noted the absence of bruising and the advanced healing of the fracture, making it difficult to repair. The injury was not recognized as acute, and the facility did not conduct a thorough investigation into the origin of the injury or consider it as a potential case of abuse or neglect, despite the resident's vulnerability and inability to communicate. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress. In this case, the lack of timely identification, reporting, and investigation of the injury, as well as the failure to interview all relevant staff and review medical reports, constituted neglect. The delay in recognizing and addressing the injury increased the risk of further harm and negative outcomes for the resident.
Failure to Conduct Thorough Abuse/Neglect Investigation for Resident Fracture
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident of abuse or neglect involving a resident who sustained a fracture. The investigation was limited in scope, as statements were only collected from two staff members, and no other staff, residents, or resident representatives were interviewed. The investigation did not expand the time frame to include the period indicated by hospital providers, and there was no evidence that the facility considered whether other residents might have been affected. Additionally, no staff were removed from the floor during the investigation, and there was no documentation of a comprehensive review or reenactment results. Medical records indicated that the resident's fracture was not acute but partially healed, suggesting the injury occurred weeks prior to its discovery. The resident was non-ambulatory, non-verbal, and dependent on staff for all activities of daily living. There was no documentation in the resident's care plan or nursing notes indicating a history of the resident putting her legs over the side of the bed, which was suggested as a possible cause of injury by staff. Interviews with staff and medical professionals revealed skepticism about the proposed cause of injury and highlighted inconsistencies in the investigation process. The facility's policy required protection of residents during investigations and comprehensive documentation, including gathering written reports from all involved parties and witnesses. However, the investigation file lacked evidence of these required steps, including documentation of interviews, findings, and actions taken to protect other residents. The investigation into the injury of unknown origin was incomplete, and there was no evidence of an abuse or neglect investigation until after the initial review was finished.
Failure to Provide Repositioning and Toileting per Care Plan
Penalty
Summary
The facility failed to provide necessary care and services consistent with a resident's assessed needs and care plan, specifically regarding repositioning, toileting, and pressure ulcer prevention. Multiple observations over several days showed that the resident remained lying flat on her back with her left lower extremity elevated on pillows, and there was no evidence of regular repositioning or side-to-side turning as required by her care plan. Staff interviews revealed inconsistent knowledge and implementation of the facility's policies for turning, repositioning, and check-and-change routines, with several staff members unable to confirm that these tasks were being performed every two hours as directed. Review of documentation for the period in question showed significant gaps in the frequency of repositioning and toileting/check-and-change activities. Records indicated that the resident was repositioned only once or twice in a 24-hour period on most days, with one day showing no repositioning at all. Similarly, documentation of toileting and check-and-change activities revealed that these were performed only once or twice per day, and on some occasions, not at all within a 24-hour period, despite the care plan's directive for these interventions to occur every two hours. Interviews with staff further confirmed that the facility's expectations for care were not consistently met in practice. Some staff members acknowledged that the two-hour schedule for turning, repositioning, and check-and-change was not always followed, and there was confusion or lack of awareness regarding the specific requirements in the resident's care plan. Policy review indicated that assistance with activities of daily living, including bed mobility and toileting, was to be provided as directed in the care plan and regularly documented, but this was not reflected in the actual care provided or in the documentation reviewed.
Failure to Assess and Address Pain in Cognitively Impaired Resident with Increased Behaviors
Penalty
Summary
The facility failed to identify and respond appropriately to increased behaviors indicative of pain or distress in a cognitively impaired resident diagnosed with dementia. Staff interviews revealed that when a resident with dementia exhibited increased behaviors such as scratching, pinching, and yelling, staff would generally assess for basic needs like pain, positioning, incontinence, and perform a head-to-toe assessment. However, despite an observed increase in these behaviors, staff could not specify when the escalation began, and behavior monitoring records showed 15 incidents of such behaviors over a five-week period. A review of the resident's pain assessments indicated that only three assessments were completed during the same timeframe, with just one coinciding with a day when the resident exhibited behaviors. The care plan included interventions to identify stressors and assess pain, but there was no evidence in the medical record that pain was consistently assessed as a possible cause for the increased behaviors. Additionally, the Minimum Data Set (MDS) assessments documented an increase in physical behavioral symptoms but indicated that the resident did not receive or was not offered PRN pain medications. This demonstrates a lack of consistent assessment and response to potential pain or distress in the resident.
Failure to Maintain Sanitary Linen Handling and Processing
Penalty
Summary
Surveyors observed multiple infection control deficiencies in the facility's laundry handling and processing. The clean side of the laundry room had floors littered with trash, used masks, dirty laundry, paper towels, and dust balls. Clean linens, including sheets and gowns, were seen dragging on these unclean floors during preparation for folding. Clean laundry that fell onto the dirty floor was picked up and placed back with other clean items. Staff were observed folding clean laundry without performing hand hygiene, and the counter in the clean folding room was missing edging, resulting in an un-cleanable surface. Staff interviews revealed that regular observations of the laundry department were not being completed, and infection control issues were acknowledged by staff during the walkthrough. Additionally, clean laundry carts were observed uncovered in various areas, including outside the linen room and in the activity room. Clean clothes on hangers were hanging on the side of the cart, and the back of the cart was uncovered. Staff confirmed that laundry carts should remain covered, as per facility policy, but admitted that this was not always maintained. A request for a policy related to cleaning the laundry room was made, but no policy was provided before the end of the survey.
Failure to Individualize and Update Activity Care Plans
Penalty
Summary
The facility failed to review and revise comprehensive care plans to accurately reflect the activity and food preferences of five residents. For each of these residents, the care plans either lacked documentation of specific activity interests or, in one case, did not include an activity plan at all. Direct interviews and observations revealed that residents participated in limited or no activities beyond what was documented, and their stated preferences or interests were not reflected in their care plans. For example, one resident attended only bible study and no other activities, while another was left at a dining table without engagement or refreshments. Another resident's family member reported that her loved one enjoyed social activities such as bowling and sewing, but these preferences were not documented or acted upon in the care plan. Staff interviews indicated a lack of awareness regarding the need to individualize and document resident preferences in the care plans, especially for those unable to attend resident council meetings. The facility's own policy requires that resident interests, hobbies, and cultural preferences be incorporated into the care plan following assessment, but this was not consistently done. The deficiency was identified through a combination of record reviews, resident and staff interviews, and direct observation.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide activities that met the individualized needs and preferences of several residents, as evidenced by multiple observations, interviews, and record reviews. Residents were often left without engagement, with some sitting idly in common areas or their rooms, and scheduled activities were not consistently provided. For example, on one occasion, residents in the dementia unit were observed sitting at tables with no staff present and no activities occurring, despite crafts being scheduled on the activity calendar. Staff interviews revealed that activities were frequently canceled or not offered, particularly when staff were pulled to cover other duties such as transportation or meal service. Several residents expressed dissatisfaction with the lack of meaningful activities. One resident reported not knowing about any activities being offered and expressed frustration with being confined to bed and not being able to listen to her preferred music. Another resident stated that he enjoyed activities but was rarely offered any, resulting in him watching television most of the time. Documentation showed that some residents attended group activities more often than preferred, despite their care plans indicating a preference for individual activities. Additionally, some residents had little to no documented participation in activities for the majority of the month. Staff interviews further revealed systemic issues, including a lack of awareness about resident preference assessments and care planning for activities, as well as missed assessments during a transition to a new electronic health record system. Family members also reported not being contacted about activity preferences for their loved ones. The facility's own policy required a resident-centered activities program, but this was not consistently implemented, resulting in unmet physical, mental, and psychosocial needs for multiple residents.
Failure to Provide Appropriate Fluids and Meal Assistance
Penalty
Summary
The facility failed to ensure that residents on the memory care unit had consistent access to appropriate fluids and adequate assistance with meals, as evidenced by multiple observations and staff interviews. One resident, who was ordered to receive mildly thickened fluids, was observed without any fluids in her room and later with a pitcher of regular, unthickened water, contrary to her care plan. Staff interviews revealed a lack of awareness regarding which residents were at risk of dehydration and inconsistent practices regarding the provision of water pitchers. Additionally, staff reported that water pitchers sometimes disappeared and that some residents did not have access to drinks unless they specifically requested them. Another resident experienced a significant weight loss of 6.5% in one month and was observed multiple times without access to fluids or assistance with meals. Her breakfast tray was left untouched as she remained asleep, and staff did not assist her with eating. Staff interviews indicated that residents on the memory care unit were not provided drinks at the bedside due to concerns about other residents consuming them and infection control. Documentation showed that the resident's hydration status was poor enough that IV fluids were considered, and staff had not coordinated with dietary services to address her preferences or needs. The facility did not provide a policy on maintaining resident hydration when requested by the surveyor.
Failure to Ensure Resident Access to Call Lights
Penalty
Summary
Surveyors observed that multiple residents did not have access to functioning call lights in their rooms or bathrooms, as required by facility policy. One resident was found lying in bed unable to reach the call light, which was hanging off the light fixture above the bed. Another resident did not know where the call light was, as it was placed under equipment on a countertop in the corner of the room, making it inaccessible. A third resident was found attempting to get up from bed without a call light present, and had to call out for help until staff responded. A fourth resident was observed sitting on the side of the bed, anxious and shaking, with no call light in the room and the bed alarm not sounding; staff had to be notified by the surveyor to assist the resident. Interviews with staff revealed that in some units, particularly the memory unit, call lights were not provided, and staff relied on regular rounding every two hours instead. Staff also indicated that some residents did not know how to use the call lights appropriately, further contributing to the lack of access. Facility policy requires that the call system be in working condition at all times and located near the patient's bed and in the restroom, but these requirements were not met for several residents, preventing them from contacting staff for assistance when needed.
Failure to Update EHR Code Status to Match Resident's POLST Form
Penalty
Summary
The facility failed to update a resident's code status in the electronic health record (EHR) from Full Code to Do Not Resuscitate (DNR) after the resident's POLST form was changed to indicate No CPR. Staff interviews revealed that there was no clear process in place for updating the EHR when a resident's code status was changed on the POLST form, and staff were unclear about whose responsibility it was to ensure the EHR matched the resident's documented wishes. A review of the resident's EHR showed the code status remained as Full Code, while the POLST form indicated No CPR. Facility policy required that advanced directives and resuscitation status be documented in the medical record, but this was not followed in this instance.
Failure to Safeguard Resident's Personal Property and Inadequate Tracking of Missing Items
Penalty
Summary
The facility failed to safeguard a resident's personal property, specifically a blanket of significant personal and religious importance, as well as some clothing items. The resident reported that his blanket, described as yellow and tan and referred to as a "Jesus blanket," had been missing for several weeks after being sent to laundry and not returned. The resident expressed distress over the loss, noting the blanket's personal meaning and his background as a Catholic priest. Interviews with staff and family confirmed the blanket's importance and the resident's repeated notifications to staff about the missing item. Family members also reported asking staff about the missing blanket on multiple occasions, with staff responses indicating uncertainty about its whereabouts and suggesting it might be in laundry. Facility staff interviews revealed inconsistencies and gaps in the process for inventorying and tracking residents' personal belongings. Not all personal items were inventoried at admission, and there was no maintained list of missing items. Staff members were unclear about the procedures for reporting and resolving missing items, with some indicating that missing items should be reported to laundry or a nurse, but no evidence was provided that the facility followed its own policy for documenting and resolving such incidents. The facility's policy required a running log of missing items and a signed resolution report, but no such documentation was available for the missing blanket.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by facility policy. The resident was admitted with impaired cognition, dementia, anxiety, frequent pain, and displayed behaviors including depression and anxiety, all of which required prompt and individualized care planning. Despite these needs, the baseline care plan was not initiated until eight days after admission and was finalized several days later. Staff interviewed were unaware of the delay or the reasons for not completing the care plan within the required timeframe. The facility's policy specifies that the admitting licensed staff must complete the nursing assessment and baseline care plan upon admission and provide a copy to the resident within 48 hours.
Failure to Implement Comprehensive Care Plan for Resident with Advanced Dementia
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident with advanced dementia. Observations revealed that the resident was repeatedly found in unsafe situations, such as rummaging through other residents' property, leaning forward in her wheelchair close to falling, and attempting to pick up objects from the floor without staff intervention. Staff did not redirect the resident, offer diversional activities, or provide necessary supervision as outlined in her care plan. The care plan specified interventions such as redirection, behavioral interventions, monitoring whereabouts, encouraging participation in activities, and observing for safety concerns, but these were not observed in practice. Interviews with staff confirmed that the resident exhibited wandering and crying behaviors, which sometimes led to negative interactions with other residents. Staff reported attempting to manage these behaviors with medication and by closing other residents' doors, but did not consistently implement non-pharmacological interventions or provide diversional activities as required by the care plan. The lack of adherence to the care plan resulted in the resident being at continued risk for falls and behavioral incidents, with staff failing to anticipate or address her needs as documented.
Failure to Remove Hazardous Liquids from Resident Access
Penalty
Summary
Facility staff failed to remove access to hazardous liquids, including hand sanitizer and perfume, in areas accessible to a resident with a documented history of alcohol use disorder and recent hospitalization for ingesting hand sanitizer. Multiple observations revealed that hand sanitizer bottles were left unattended on top of medication carts, at the nursing station, and on counters within resident reach. Additionally, a bottle of perfume was found in an open cabinet accessible to residents. These hazardous items remained accessible despite the known risk posed by the resident's behavior. Interviews with staff confirmed awareness of the resident's history of drinking hand sanitizer, with staff stating that wall-mounted dispensers had been emptied for this reason. However, staff also acknowledged that hand sanitizer bottles should not be within resident reach and should be stored securely. One staff member indicated there was no specific policy regarding keeping hazardous chemicals, such as hand sanitizer, out of resident access. The facility's failure to secure these substances resulted in continued exposure of the resident to accident hazards.
Failure to Provide Necessary Behavioral Health Services for Residents with Ongoing Behavioral Issues
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with significant behavioral and psychosocial needs. One resident with advanced dementia was repeatedly observed engaging in unsafe wandering behaviors, such as entering other residents' rooms, rummaging through belongings, and nearly falling from her wheelchair and bed. Staff reported that this resident frequently cried, wandered, and was the target of negative interactions from other residents, including yelling and having objects thrown at her. Despite these ongoing behaviors, the care plan only included general interventions such as offering reassurance and social services follow-up as needed. Social services staff confirmed they did not actively address the resident's emotional or psychosocial needs, focusing instead on unrelated issues, and there was no documentation of behavioral health assessments or interventions for her continued distress and behaviors. Another resident exhibited frequent verbal and physical aggression, including yelling profanities at other residents, physically threatening staff, entering other residents' rooms, and engaging in inappropriate behaviors such as defecating in another resident's refrigerator. Nursing notes documented multiple incidents of aggression and wandering over several days, with staff reporting that these behaviors occurred nightly and sometimes required security intervention. The care plan for this resident also only referenced general psychosocial support and social services follow-up as needed, without evidence of targeted behavioral health interventions or assessments. Interviews with staff revealed a lack of active involvement from social services in addressing behavioral health issues for both residents. The staff member responsible for behavioral health consultations was unaware of the ongoing behaviors and had not been asked to provide input or interventions. There was no evidence that the facility had assessed or implemented appropriate behavioral health services to address the residents' needs, as required by their comprehensive assessments and care plans.
Failure to Initiate Speech Therapy Referral for Resident with Mental Health Needs
Penalty
Summary
A deficiency occurred when the facility failed to ensure a referral was made for cognitive rehabilitation with a speech therapist for one resident who had been evaluated for depression, schizophrenia, and bipolar disorder. The resident's Behavioral Health Outpatient Psychosocial Evaluation indicated a need for cognitive rehabilitation with a speech therapist, and the plan included a referral for this service. However, interviews with facility staff revealed that no referral or speech therapy notes could be found for the resident, and there was confusion between the facility and the outpatient provider regarding responsibility for initiating the referral. This resulted in an almost six-month delay in implementing the recommended speech therapy treatment for the resident.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs. Resident #5 reported experiencing back pain from lying in bed too long due to insufficient staff to assist her in getting up. Similarly, Resident #3 expressed frustration over not being assisted out of bed at his preferred time, often having to wait until late morning. Resident #4 experienced a delay in toileting assistance, leading to an incontinence episode, with call light records showing multiple instances of prolonged wait times. Staff interviews revealed that the facility was commonly short-staffed, impacting the ability to provide timely care, including morning routines and incontinence care. Staff member J noted the difficulty in finding assistance for residents requiring more complex care, such as those needing a Hoyer lift. Staff member L highlighted the challenges in completing activities of daily living (ADL) care within the allotted time, while staff member I pointed out the unrealistic expectations given the staffing levels. The facility's call light policy aimed for a 15-minute response time, but records indicated numerous instances of significantly longer wait times. The staffing shortage was attributed to various factors, including difficulty in hiring, high turnover, and scheduling issues. Staff member E mentioned challenges in finding willing workers and dealing with attendance issues. The facility's previous attempt at self-scheduling led to discrepancies and dissatisfaction among staff, further complicating the staffing situation. The management acknowledged the ongoing staffing issues and the need for time to address them, with a tentative plan to stabilize schedules in the near future.
Deficient ADL Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for three residents, leading to potential health risks. Resident #5 was observed in bed complaining of back pain due to prolonged lying and reported frequent delays in receiving help to get up. The care plan indicated the need for assistance with transfers and incontinence care, yet the resident experienced significant wait times for assistance. Resident #3 expressed dissatisfaction with the delay in being assisted out of bed, which was significantly later than his preferred time. The resident had a chronic pressure ulcer and moisture-associated skin breakdown, conditions that could be exacerbated by the delays in care. Staff interviews confirmed that the lack of timely assistance could negatively impact the healing process of the resident's ulcer. Resident #4 reported long wait times for toileting assistance, resulting in incontinence episodes, and infrequent showers, which were not documented accurately. Staff interviews revealed that the facility was short-staffed, leading to delays and omissions in care, including incontinence care and showering. The staffing ratio was insufficient to meet the residents' needs, causing some care tasks to be skipped or performed inadequately.
Failure to Individualize Dementia Care and Monitor Wanderguard Use
Penalty
Summary
The facility failed to individualize interventions for residents with dementia in the memory care unit, specifically regarding the use of wanderguards. The facility did not assess the effectiveness of the wanderguard intervention after incidents of elopement. Additionally, the facility did not follow protocol when obtaining verbal consent for the placement of wanderguards on residents. This was evident in the cases of three residents who were sampled for elopement concerns. The facility's policy required a second witness for verbal consent, which was not adhered to in these instances. One resident eloped from the facility by following a staff member out of the memory care unit and was later found on the facility campus. Another resident eloped by following a staff member out of the activity room, which was not located in the memory care unit. The facility did not monitor the activity room door to ensure the safety of dementia residents attending activities outside the secured unit. Interviews revealed that staff were not aware of the placement of wanderguards on certain residents, and there was confusion about whether consent had been given. The facility did not complete wanderguard assessments or have a schedule for checking the functionality of the wanderguards. Staff members reported that residents were frequently in and out of the memory care unit, which they believed was sufficient for checking the status of the wanderguards. However, one resident was able to remove the wanderguard and place it in a sock drawer, indicating a lack of effective monitoring. The facility also failed to provide education to staff about dementia residents and the use of wanderguards, contributing to the deficiency.
Failure to Address Behavioral Health Needs After Resident Altercation
Penalty
Summary
The facility failed to identify, address, and obtain necessary services for the behavioral health care needs of two residents involved in an altercation. Resident #13 and Resident #71, who were initially friends, engaged in a physical altercation where they hit each other. Resident #71, who has a developmental delay, was not provided with an updated PASARR Level 1 after his convalescent stay, despite having a previous PASARR Level 2 due to his diagnoses of microencephaly and developmental delay. The care plan for Resident #71, which started in February 2024, lacked updates or new interventions related to altercations with other residents or specific to his diagnoses. Additionally, there were no notes from social services or behavioral health services in Resident #71's electronic health record. Resident #13, diagnosed with bipolar disorder, neurocognitive deficit, PTSD, schizophrenia, depression, anxiety, and a history of traumatic brain injury, also had a care plan that was not updated with new interventions following the altercation. The care plan only mentioned that Resident #13's psychosocial needs would be met as needed, with social services following up as necessary. Interviews with staff and residents revealed that neither resident was being followed by social services or behavioral health services, and communication with family members about incidents was inadequate.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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