Benefis Senior Services - Grandview
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Falls, Montana.
- Location
- 3015 18th Ave S, Great Falls, Montana 59405
- CMS Provider Number
- 275157
- Inspections on file
- 8
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Benefis Senior Services - Grandview during CMS and state inspections, most recent first.
A staff member did not perform hand hygiene before donning gloves and failed to disinfect a handheld glucometer between uses while conducting blood glucose monitoring for two residents. The device was placed on various surfaces and returned to storage without cleaning, contrary to facility policy and staff knowledge.
Three residents were admitted and began receiving care, including oxygen therapy and, in one case, urinary catheter care and extensive ADL assistance, but their baseline care plans did not include necessary problems, goals, or interventions for these needs. Staff interviews confirmed that baseline care plans were not always comprehensive, omitting key information required for effective and person-centered care.
Surveyors found that several residents received oxygen therapy without provider orders specifying the delivery rate, and there was no consistent documentation or labeling of when oxygen tubing was last changed. Additionally, a nebulizer machine and mouthpiece were observed on the floor next to a trash can, with the mouthpiece touching the floor and covered with used tissues, indicating a lapse in infection control practices.
A resident who received Medicare Part A skilled services was not given the required SNF Beneficiary Notification (CMS-10055) upon discharge from skilled care. Staff confirmed the form was not completed and could not provide a reason for the omission, and facility records did not show evidence that the notification was provided.
The facility did not ensure that PRN psychotropic medication orders were limited to 14 days or had documented rationale for extended use. Two residents had PRN orders for alprazolam and lorazepam that lacked appropriate stop dates or exceeded the 14-day limit, with staff acknowledging the oversight and expressing uncertainty regarding hospice care exceptions.
A resident and their representative were not given written notification of the facility's bed hold policy when the resident was transferred to the hospital, as confirmed by staff and a review of facility policy.
Two residents receiving oxygen therapy did not have this intervention addressed in their care plans, and one resident with a recent aspiration event and documented swallowing difficulties lacked care plan interventions for aspiration risk. Staff confirmed these omissions, despite the needs being identified in MDS assessments.
Two residents experienced multiple falls, but their care plans were not updated to reflect the incidents or to include new interventions based on root cause analysis. Despite established processes for event reporting and fall committee review, care plans remained unchanged after each fall, leaving interventions outdated.
A staff member was observed preparing multiple residents' breakfast trays in the kitchen while wearing a hairnet but not a beard net, despite having facial hair that required coverage according to facility policy. The staff member and other employees confirmed that a beard net should have been worn during food preparation.
The facility failed to respond to call lights in a timely manner for three residents, with documented wait times significantly exceeding the expected seven to nine minutes. One resident reported waiting up to 20 minutes, while another experienced a two-hour delay. A third resident, after waiting over 45 minutes, attempted to move without assistance, resulting in a fall. These delays indicate a failure in the facility's response system.
A resident was discharged from an LTC facility without meeting rehabilitation goals and without necessary home health services in place. The resident, who had a wound/fistula and required multiple medications, was sent home alone, leading to safety concerns and potential medication errors. The facility failed to ensure that physical therapy, occupational therapy, and skilled nursing services were arranged prior to discharge, resulting in a deficiency in the discharge process.
Failure to Follow Infection Control Protocols During Blood Glucose Monitoring
Penalty
Summary
Staff member C failed to follow proper infection control practices during blood glucose monitoring for two residents. Specifically, staff member C did not perform hand hygiene before donning gloves prior to testing a resident's blood glucose. After completing the blood glucose monitoring, staff member C placed the handheld glucometer on various surfaces, including a supply cart and the medication cart, without cleaning or sanitizing the device between uses or after use. The glucometer was then returned to the locked supply room and placed on the charger without being disinfected. Interviews with staff members confirmed that the facility's policy requires the glucometer to be disinfected with appropriate wipes between each resident use and after the last use before returning it to the charger. Staff also acknowledged that hand hygiene should be performed before donning gloves and after glove removal. Despite this, staff member C did not adhere to these protocols, as observed and confirmed during interviews. The facility's policy, last revised in February 2024, clearly outlines these infection prevention requirements.
Failure to Include Essential Needs in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the minimum necessary instructions to provide effective and person-centered care for three of seventeen sampled residents. Specifically, observations revealed that multiple residents were receiving oxygen therapy, but their baseline care plans did not address problems, goals, or interventions related to oxygen use. One resident, who also had a urinary catheter due to urinary retention and required extensive assistance with activities of daily living (ADLs) because of a cancer diagnosis, did not have these needs reflected in the baseline care plan. Interviews with staff confirmed that baseline care plans were initiated at admission but did not consistently include all required information for continuity of care. Staff acknowledged that areas such as ADLs, pain, urinary issues, falls, psychotropic medications, and oxygen therapy should be included, but these were sometimes omitted. Additionally, staff noted that some aspects of the computer system used for care plan entry needed to be addressed to ensure thorough completion of baseline care plans.
Deficient Respiratory Care: Incomplete Oxygen Orders, Poor Tubing Documentation, and Infection Control Lapses
Penalty
Summary
The facility failed to ensure that oxygen therapy orders for several residents included a specific rate of oxygen delivery. Observations revealed that multiple residents were receiving oxygen via nasal cannula, but their provider orders only specified to maintain oxygen saturation above a certain percentage, without indicating the exact flow rate. In some cases, contradictory orders were present, and staff interviews confirmed that orders often lacked a defined rate, especially when transferred from hospital records. This omission was noted for four residents, with staff acknowledging the issue and attributing it to the electronic medical record systems used. Additionally, the facility did not maintain proper documentation or labeling to indicate when oxygen tubing was last changed for several residents. During observations, none of the oxygen tubing in use had visible dates or labels showing the last change, despite facility policy requiring weekly changes and documentation. Staff interviews revealed uncertainty about where or if tubing changes were documented, and it was noted that a recent staffing mix-up may have contributed to the lack of labeling. A whiteboard in the nurse's lounge outlined the process, but this was not consistently followed in practice. Furthermore, infection control practices were not adhered to regarding respiratory equipment. One resident's nebulizer machine and mouthpiece were observed on the carpeted floor next to a trash receptacle, with the mouthpiece touching the floor and covered with used tissues. Staff confirmed that this did not meet infection control standards and acknowledged that the resident was unlikely to have placed the equipment there independently. The resident had a current order for nebulized albuterol four times daily, indicating frequent use of the equipment.
Failure to Provide Required SNF Beneficiary Notification for Medicare Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Beneficiary Notification, Form CMS-10055, to one of three sampled residents who received Medicare Part A skilled services. During an interview, a staff member confirmed that the notification form was not completed when the resident was discharged from skilled care services and was unable to explain the omission. Review of facility records showed the resident's Medicare Part A skilled services began on 4/10/25 and ended on 5/12/25, but there was no evidence that the required notification form was provided to the resident.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed on an as-needed (PRN) basis were limited to 14 days unless there was documented rationale for continued use in the medical record. For one resident, an order for alprazolam 0.25 mg to be given nightly as needed did not include a stop date or a 14-day limitation. Staff confirmed that such orders should have a stop date. For another resident on hospice, there were two active PRN orders for lorazepam with a one-year end date, both exceeding the 14-day limit without documented justification in the medical record. Staff indicated uncertainty about the appropriateness of longer PRN orders for hospice residents.
Failure to Provide Written Bed Hold Policy Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident and/or the resident's representative when the resident was transferred to the hospital. During an interview, a staff member confirmed that there was no documentation of the required notification for this hospitalization. Review of the facility's own policy indicated that written notification of the room hold policy is required for residents and/or their representatives.
Failure to Include Oxygen Therapy and Aspiration Risk in Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing all identified needs for two residents who were receiving oxygen therapy and for one resident with an increased risk of aspiration following a recent hospitalization for aspiration and respiratory failure. Observations confirmed that both residents were receiving oxygen via nasal cannula, and interviews with staff and residents revealed inconsistencies in the monitoring and supervision of meals, particularly for the resident with a history of aspiration. Documentation review showed that the Minimum Data Set (MDS) assessments for both residents indicated the use of oxygen therapy, and for one resident, documented swallowing difficulties and a history of aspiration. Despite these documented needs, the comprehensive care plans for both residents did not include problems, goals, or interventions related to oxygen therapy. Additionally, the care plan for the resident with a history of aspiration did not address the increased risk for aspiration or swallowing difficulties. Staff interviews confirmed that these care areas should have been included in the care plans, as identified by the MDS assessments.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to update and revise care plans to reflect actual falls and implement new interventions for two residents following multiple fall incidents. For one resident, despite a documented unwitnessed fall from bed and noted impulsivity, the care plan did not include the fall event, the resident's impulsive behavior, or any new interventions post-fall. Staff interviews revealed uncertainty about the interventions in place and reliance on care plans for guidance, but the care plan remained outdated. For another resident, multiple falls were documented, including incidents where the resident was found on the floor or partially out of bed and wheelchair, with some resulting in injuries. Although the facility had a process for event reporting and a fall committee that met regularly, the resident's care plan was not updated with new interventions after each fall to address the root causes. The care plan only reflected interventions implemented shortly after admission, with no subsequent updates following the documented falls.
Failure to Use Beard Net During Food Preparation
Penalty
Summary
A staff member was observed preparing four individual residents' breakfast trays in the kitchen area while wearing a hairnet but not a beard net, despite having facial hair. During interviews, the staff member acknowledged that a beard net should have been worn, and other staff confirmed that both a hairnet and beard net are required when preparing food if indicated. Review of the facility's Food & Nutrition Services Dress Code policy confirmed that facial hair longer than 1/4 inch must be restrained with a facial hair covering while in food service areas. This lapse in following established sanitary hygiene practices was directly observed during food preparation.
Delayed Call Light Response and Resident Fall
Penalty
Summary
The facility failed to ensure that call lights were answered in an appropriate timeframe for three residents, leading to significant delays in response times. Resident #10 reported waiting up to 20 minutes for assistance, particularly during shift changes or after 6:00 p.m., and noted that staff would sometimes turn off the call light without addressing all her needs. The facility's call history confirmed that eight out of fifteen call light uses for this resident exceeded 15 minutes, with some waits extending up to an hour. Resident #6 also experienced prolonged wait times, with 13 out of 14 call light uses exceeding 15 minutes, including one instance of a two-hour wait. Resident #5 reported waiting over 45 minutes for assistance, and in one instance, attempted to get up without staff help, resulting in a fall. The call history for this resident showed multiple instances of extended wait times, including a 59-minute wait. The facility's expectation for call lights to be answered was stated to be seven to nine minutes, as per staff member A. However, the documented wait times for the residents significantly exceeded this expectation, indicating a failure in the facility's response system. The delays in responding to call lights not only compromised the residents' ability to have their needs met promptly but also contributed to a fall incident for one resident who attempted to move without assistance due to the prolonged wait.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was sent home alone without meeting his rehabilitation goals. The resident had a wound/fistula, required multiple medications, and needed ongoing rehabilitation services. Despite these needs, the resident was discharged without the necessary home health services in place, increasing the risk of a poor outcome and safety concerns due to his inability to care for himself. Interviews revealed that the resident was discharged without home health services, physical therapy, or occupational therapy being initiated. The family, who lived nearby but were not planning to provide full-time care, had not seen any home health services since the discharge. The resident struggled with mobility, requiring assistance to reach his apartment, and was unable to manage his medications, leading to concerns about potential medication errors. The facility staff member responsible for setting up these services did not follow up to ensure they were in place, and the family was left without support until a scheduled appointment with a new primary care provider. The resident's discharge paperwork lacked instructions for wound care or fistula management, and he had not met several occupational and physical therapy goals necessary for a safe return home. The resident expressed that he did not feel prepared for discharge, and the facility's failure to ensure necessary services were in place prior to discharge put him at risk for negative outcomes. The facility's actions and inactions led to a deficiency in providing a safe discharge process for the resident.
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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