Benefis Senior Services - Westview
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Falls, Montana.
- Location
- 500 15th Ave S, Great Falls, Montana 59405
- CMS Provider Number
- 275158
- Inspections on file
- 8
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Benefis Senior Services - Westview during CMS and state inspections, most recent first.
A resident was subjected to mental abuse when staff restricted her right to private in-room visitations, requiring all visits with certain individuals to occur only in common areas for staff convenience. This restriction was imposed without documented safety concerns, contradicted the resident's care plan preferences for socialization, and led to the resident experiencing ongoing feelings of isolation, frustration, and being watched.
A resident with a history of skin breakdown developed a worsening Stage III pressure ulcer due to inconsistent wound assessment, measurement, and dressing changes, with staff failing to follow physician orders and facility policy for documentation. Another resident with an indwelling catheter developed a wound on the foreskin after staff failed to provide consistent and proper perineal care, and the wound went undocumented and unrecognized by staff until observed during the survey.
Two residents did not have comprehensive, person-centered care plans in place to address their specific needs. One resident's care plan lacked critical details for dialysis management, such as monitoring protocols and emergency contacts. Another resident with cognitive impairment and a history of elopement did not have interventions or risk identification documented in the care plan, despite repeated incidents and discussions about moving to a secure unit.
A resident with severe cognitive impairment repeatedly accessed unmonitored elevators and was found on other floors or searching for exits, yet was not assessed as at risk for elopement and did not have interventions reflected in the care plan. Staff were unclear on elopement definitions, did not use the wander guard system, and failed to move the resident to a secure unit despite available beds, resulting in ongoing elopement hazards.
Insufficient nursing staff resulted in delayed wound care, inconsistent completion of ADLs, and prolonged call light response times. A resident's pressure ulcer worsened due to missed dressing changes and lack of wound monitoring, while other residents experienced delays in hygiene care and repositioning. Staff and residents reported frequent low staffing, with only one nurse and two CNAs at times for 34 rooms, directly impacting the quality and timeliness of care.
A resident was not allowed to have visitors in her room and was only permitted to meet with friends in the common area, as directed by staff. Staff interviews revealed inconsistent understanding of visitation rules, and the facility only had a hospital-wide policy, not one specific to LTC. Staff confirmed there was no developed or communicated visitation policy for long-term care services, affecting all residents and their visitors.
Two residents experienced a lack of privacy: one was not permitted to have private visits in her room and was required to meet visitors in a non-private common area, while another did not have a door or curtain on her bathroom, leaving her feeling exposed. Staff were either unaware of or responsible for these privacy lapses, which were contrary to the facility's stated policies on resident rights.
A resident was found with a wheelchair seat belt restraint that they could not remove independently, without a current physician order, documented medical justification, or inclusion in the care plan. Staff indicated the restraint was used for fall prevention, but facility policy requiring assessment, documentation, and care planning for restraints was not followed.
A nurse pre-poured and scanned medications for several residents, documenting them as administered in the MAR before actually giving them. Medications were then administered at later times than recorded, resulting in inaccurate documentation for at least three residents. The nurse admitted this practice occurred, especially when short-staffed or running behind, and acknowledged it was improper.
Two residents did not consistently receive assistance with basic ADLs, such as hair and oral care, and were sometimes left in their rooms without encouragement to participate in meals or social activities. Staff interviews and observations indicated a reliance on family members to provide these cares, rather than ensuring staff completed them.
Several residents with limited mobility were not regularly repositioned by staff, resulting in prolonged periods in the same position without the use of positioning aids. Residents reported discomfort, soreness, and concerns about skin breakdown, while staff interviews indicated that the restorative aide was overextended and CNAs were not consistently providing necessary turning and mobility assistance.
A resident receiving hemodialysis did not have a physician order for dialysis documented upon admission, with the order only created months later. The resident also reported not receiving adequate protein with a meal and expressed dissatisfaction with the available options. Staff confirmed the resident should have received double protein servings and that alternatives were available, but these were not provided.
Surveyors identified that staff failed to properly administer and document medications for three residents, including not verifying or recording vital signs before giving digoxin, not providing a prescribed topical cream as documented, and not administering an inhaler despite documentation stating otherwise. These actions resulted in a medication error rate of nine percent.
A resident with significant hand deformities and discomfort from a previous bone break experienced a three-month delay in receiving an orthopedic consult due to the facility's failure to follow up on a referral. Although the referral was ordered, it was not completed because the orthopedic provider contacted the resident's personal cell phone instead of the unit, and nursing staff did not ensure the follow-up was finalized.
The facility failed to serve food at safe and appetizing temperatures, affecting several residents. Observations revealed that food was often cold, and staff relied on microwaving without proper temperature checks, contrary to facility policy. Residents reported dissatisfaction with meal temperatures, and staff admitted to reheating food primarily due to surveyor presence.
The facility failed to honor resident preferences for shower frequency, with three residents reporting dissatisfaction with the current schedule. They expressed a desire for more frequent showers, but the facility's documentation did not reflect any refusals or unavailability. Staff interviews indicated that showers were often postponed due to other tasks, but these instances were not documented, and the facility lacked a specific policy addressing shower frequency and preferences.
The facility failed to provide scheduled bathing assistance to three residents, resulting in extended periods without showers. Despite being scheduled for regular showers, these residents experienced significant gaps between bathing sessions, with no documentation of refusals or unavailability. Interviews confirmed infrequent showers, indicating a failure to adhere to the facility's policy on personal hygiene assistance.
A resident with significant health issues, including skin concerns and mobility limitations, did not have a comprehensive care plan addressing all their needs. The care plan lacked documentation for essential ADLs and did not reflect the resident's nutritional needs for healing. Staff interviews highlighted challenges in completing scheduled care tasks, such as showers, due to workload and resident availability.
Resident Subjected to Mental Abuse Through Restriction of Visitation Rights
Penalty
Summary
The facility failed to ensure a resident was free from mental abuse by depriving her of her rights to private visitations and by isolating her from social interactions for staff convenience. The resident was not allowed to have visitors in her room and was repeatedly told by staff to move her visits to the common area. This restriction was imposed despite the resident expressing that socialization was very important to her and that the limitation caused her to feel dull, bored, frustrated, and like a prisoner. The restriction had been in place for several months, and the resident agreed to it only to keep peace with the staff, not because she felt it was appropriate. Multiple staff interviews confirmed that the directive to limit the resident's in-room visitors originated from a specific staff member, who cited concerns about the resident discussing facility issues with others and encouraging complaints. There were no documented safety concerns or incidents that justified the restriction, and staff acknowledged that the resident's visitors, including a long-time friend and another resident's family member, were not involved in any inappropriate behavior. The facility did not provide the resident with written documentation or rationale for the visitation limitation, and the decision was not based on any documented behavioral or safety issues. The resident's care plan indicated a preference for socialization and maintaining her current level of social interaction, with a goal of avoiding complaints of isolation. However, the imposed visitation restrictions directly contradicted these care plan goals and the facility's own policies, which guarantee residents the right to private visits and to voice concerns without fear of punishment. The actions taken by staff resulted in the resident experiencing ongoing negative psychosocial effects, as evidenced by her own statements and corroborated by interviews with friends and staff.
Failure to Consistently Assess, Document, and Provide Wound and Perineal Care
Penalty
Summary
The facility failed to consistently assess, measure, and monitor a resident's pressure ulcer, and did not ensure wound dressings were provided as ordered by the physician. One resident with a history of Addison's disease and susceptibility to skin breakdown developed a Stage III pressure ulcer on the back of her right upper thigh after readmission from the hospital. The resident reported that staff did not listen to her instructions on wound dressing application, resulting in dressings that frequently rolled up and came off. She also stated that dressing changes were not performed consistently, and wound care was not always provided as scheduled. Observations confirmed the presence of a worsening wound, and record reviews showed a lack of consistent wound assessment, measurement, and documentation between physician visits, despite facility policy requiring regular monitoring and documentation. Staff interviews revealed that wound care and assessments were primarily performed by a wound care nurse who visited weekly, but measurements were not always taken at each dressing change, and sometimes the nurse did not return to complete wound care if the resident was unavailable. Other nursing staff were expected to perform dressing changes as ordered, but documentation was inconsistent or missing for multiple dates. The resident's wound progressed from improving to worsening over a period of several weeks, as documented by the Wound Clinic physician, with a significant increase in wound size. Facility records and task histories confirmed that dressing changes and wound assessments were not completed or documented as required by physician orders and facility policy. Additionally, the facility failed to ensure proper perineal care for another resident with an indwelling catheter, resulting in the development of a wound on the foreskin. The resident reported inconsistent perineal care and that staff often failed to properly clean the area, especially under the foreskin. Staff were unaware of the wound until it was observed during the survey, and there was no prior documentation or notification regarding the wound. The lack of proper perineal care and failure to identify and document the wound contributed to the resident's condition.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet care needs. For one resident with multiple diagnoses including congestive heart failure, diabetes, and pulmonary fibrosis, the care plan did not include essential details related to dialysis care. Missing elements included the dialysis center's contact information, specifics on monitoring pre- and post-dialysis vitals, transportation arrangements, the type and location of dialysis, which arm to use for blood pressure, emergency contacts for dialysis-related issues, and monitoring for complications such as infection or hypotension at the access site. Another resident with cognitive impairment, ataxia, and a history of traumatic brain injury experienced repeated elopement incidents. The care plan did not identify the resident's elopement risk or outline interventions to prevent further incidents, nor did it include person-centered activities or diversions tailored to the resident's interests or dementia progression. Despite multiple documented elopements and discussions about transferring the resident to a secure unit, the care plan was not updated to reflect these risks or interventions.
Failure to Identify and Address Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The facility failed to timely identify and address elopement risks for a resident with severe cognitive impairment. The resident, who had a BIMS score of 7 indicating severe cognitive deficits, was not assessed as being at risk for elopement in the most current available assessment, and no updated elopement assessment was provided during the survey. Despite repeated incidents where the resident accessed elevators and was found on other floors or searching for exits, the care plan did not reflect the resident's wandering or elopement risk, nor did it provide staff with guidance on managing these behaviors. Multiple nursing notes documented the resident's repeated attempts to use the elevator and leave the unit, including instances where the resident was found on different floors and continued to seek exits for extended periods. Staff attempted to redirect the resident without success, and discussions occurred about moving the resident to a secure unit. However, there was no documented follow-up or implementation of this intervention, even though secure unit beds were available in the facility. Staff interviews revealed a lack of awareness and understanding regarding the classification of elopement events, with some staff considering the incidents as AWOL rather than elopement, despite the resident's cognitive impairment. Additionally, the facility's wander guard system was not utilized for this resident, and staff were unsure how it functioned on the unit. The facility had unmonitored elevators and exits, further contributing to the ongoing elopement hazard for the resident.
Insufficient Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several care deficiencies. One resident with a pressure ulcer on her right upper leg reported that her dressing was not changed consistently, particularly during the day when staff stated they did not have time. Medical record review confirmed that the wound was not assessed, measured, or monitored for nearly a month, and a Wound Clinic note documented that the pressure injury worsened during this period. Staff interviews corroborated that dressing changes were not completed as ordered and that wound care documentation was lacking. Other residents experienced unmet needs related to activities of daily living (ADLs) and long call light response times. One resident was often left in her room in the dark during breakfast, missing opportunities for socialization and encouragement to eat. Another resident reported waiting an hour and a half to be changed and stated that basic hygiene tasks such as face washing and hair brushing were inconsistently performed. Observations confirmed that at times, no CNAs were present on the floor, and staff reported that the unit was frequently staffed with only one nurse and two CNAs for 34 rooms, with some residents requiring two-person assistance for transfers. Multiple residents and staff expressed concerns about low staffing levels, with reports of call lights going unanswered for extended periods and residents feeling reluctant to request assistance. Staff described being floated to other buildings and feeling short-staffed more than half the time. The call light system was also reported to be down, preventing the facility from providing call light response data. These staffing shortages directly contributed to delays in care, incomplete ADLs, and inadequate repositioning for residents at risk of skin breakdown.
Failure to Develop and Communicate LTC-Specific Visitation Policy
Penalty
Summary
The facility failed to develop, implement, and inform residents of a specific visitation policy and procedure for long-term care services. One resident reported being restricted from having visitors in her room and was only allowed to meet with friends in the common area, as directed by staff. The resident stated she complied with this arrangement to avoid conflict with staff. Multiple staff interviews revealed inconsistent understanding and application of visitation policies, with some staff indicating that overnight visits required prior approval and others referencing a general hospital policy rather than one tailored to long-term care. Upon request, the facility provided a visitation policy that was specific to the hospital system and not applicable to the long-term care setting. Staff confirmed that there was no developed policy or procedure for visitation related to Senior Services or long-term care. This lack of a specific and communicated visitation policy had the potential to affect all residents and their visitors, as it resulted in inconsistent practices and lack of clarity regarding residents' visitation rights.
Failure to Ensure Resident Privacy During Visits and Bathroom Use
Penalty
Summary
The facility failed to ensure resident privacy in two separate instances. One resident was not allowed to have visitors in her room and was instructed by staff to meet with visitors only in the common area, which did not provide privacy for conversations. Multiple staff interviews confirmed that this restriction was imposed by a staff member, and the facility's own policy and resident rights documentation state that residents are entitled to private visits and to have visitors at any time. In another case, a resident's bathroom lacked a door or privacy curtain, leaving the bathroom open to the main living space. The resident expressed discomfort and a sense of exposure, particularly when showering. Staff were unaware of the resident's concerns, despite facility policy stating that residents are entitled to proper privacy, property, and living arrangements.
Failure to Document and Justify Use of Physical Restraint
Penalty
Summary
A resident was observed sitting in a wheelchair near the nurse's station with a loose-fitting seat belt that the resident was unable to remove independently when prompted. The resident's records showed that the last assessment for the use of restraints or alarms was completed nearly three years prior, and this evaluation did not specify any medical condition or symptom being treated by the use of the seat belt. There was no documentation in the resident's electronic health record of ongoing re-evaluation for the need for a physical restraint, and the most recent care plan did not mention the use of a seat belt. During staff interview, it was stated that the seat belt was used to prevent falls and that care plans are typically updated after such events, but the staff member was unaware that the seat belt was not included in the current care plan. Additionally, there was no physician order for the use of the wheelchair seat belt, as required by the facility's own policy. The policy mandates a physician's order with documented rationale, appropriate nursing assessment, and care plan initiation for any restraint, as well as quarterly reassessment for restraint reduction, none of which were present in this case.
Inaccurate Medication Administration Times Documented in MARs
Penalty
Summary
The facility failed to ensure that pre-poured medications were administered in a timely manner and that medication administration records (MARs) accurately reflected the actual times medications were given. During observation and interviews, a staff member was found to have pre-poured medications for multiple residents and stored them in a locked medication cart drawer. The staff member scanned the medications into the MAR as if they had been administered at that time, even though the medications were not actually given until later. The staff member admitted to sometimes changing the administration time in the MAR to match the actual time, but on the day of observation, did not do so due to being late and running behind. The staff member also indicated that this practice occurred more frequently when the facility was short-staffed and acknowledged that this method was incorrect. Specific instances were observed where residents received their medications at times that did not match the times documented in their MARs. For example, one resident received medications at 8:14 a.m., but the MAR showed administration at 7:32 a.m.; another received medications at 8:19 a.m., with the MAR indicating 7:38 a.m.; and a third resident received medications at 8:28 a.m., while the MAR documented 8:03 a.m. These discrepancies resulted in inaccurate documentation of medication administration times for at least three residents. Staff interviews confirmed that this practice was unacceptable and did not meet professional standards of quality.
Failure to Provide Consistent ADL Support and Reliance on Family for Care
Penalty
Summary
Staff failed to ensure that two residents received assistance with basic activities of daily living (ADLs), such as hair and oral care, as well as support to get out of bed and participate in meals and social activities. One resident, who had a history of stroke and was unable to brush the right side of her hair, reported that her face was only sometimes washed in the morning and her hair was only partially brushed. Observations confirmed that her hair and teeth were not consistently cared for, and a staff member noted that they often provided these cares only when a family member was present, raising concerns about what would happen if the family member did not visit daily. Another resident was frequently left in her room in the dark during breakfast, not encouraged to get out of bed, eat, or socialize with others. Observations showed that her hair remained in frizzy braids that appeared to have been slept in throughout the morning. Staff interviews revealed a pattern of relying on family members to complete basic ADLs, rather than ensuring staff provided these essential cares.
Failure to Reposition Residents to Prevent Skin Breakdown
Penalty
Summary
The facility failed to ensure that residents with limited mobility were regularly repositioned to prevent skin breakdown. Multiple residents reported that staff only repositioned them upon request, and observations confirmed that residents remained in the same position for extended periods without the use of positioning aids such as pillows or wedges. One resident noted that staff applied cream to her buttock area, which was observed to be slightly pink and blanchable, but she was not informed about the condition of her skin. Another resident reported soreness from prolonged sitting and was not observed to be repositioned during the survey period. Documentation showed that one resident was not turned at all on several days. Staff interviews revealed that the restorative aide responsible for mobility and repositioning services was covering approximately 70 residents across three buildings, and that CNAs could assist with turning and repositioning, but nurses were described as too busy to help. Residents expressed concerns about inadequate cleaning and the risk of skin breakdown, with some reporting recurrent UTIs and discomfort from prolonged immobility. The electronic health records did not consistently reflect the residents' actual skin conditions or repositioning needs.
Failure to Ensure Physician Orders and Appropriate Nutrition for Dialysis Patient
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring hemodialysis. The resident, who regularly attended dialysis at an off-site center, did not have a physician order for dialysis treatment documented upon admission, with the order only being created several months later. Additionally, the resident reported not receiving adequate protein with a supper meal, expressing dissatisfaction with the lack of meat options and stating he was tired of chicken. Staff confirmed that the resident should have been receiving double servings of protein and that alternative options were available if the resident did not want chicken. Observations confirmed the resident was not present to eat the meal provided, which included green beans, a bun, chicken noodle soup, and pumpkin pie, and did not include a protein alternative as per the resident's dietary needs and preferences.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for three residents, resulting in a medication error rate of nine percent. For one resident prescribed digoxin, staff administered the medication after stating they had taken the resident's pulse earlier in the morning, but there was no documentation of any vital signs, including pulse, on the day of administration. The physician's order for digoxin specified to hold the medication if the pulse was less than 50, but this parameter was not verified or documented at the time of administration. Additionally, another resident did not receive their prescribed Lotrimin cream as documented on the Medication Administration Record (MAR), despite the staff member stating they would return to administer non-pill medications after distributing oral medications. The resident, who was cognitively intact, reported not receiving the cream and indicated this was a recurring issue. A third resident, also cognitively intact, reported not receiving their inhaler, although the MAR indicated it had been given. These failures were observed and confirmed through interviews, record reviews, and direct resident statements.
Delay in Orthopedic Referral Follow-Up for Resident with Hand Deformities
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely follow-up on a referral for an orthopedic consult for a resident with significant deformities and discomfort in her right hand, specifically the index and ring fingers, resulting from an old bone break. The resident had requested to see an orthopedic doctor, and a referral to a hand surgeon was documented in the physician's progress notes. However, a review of the electronic medical record did not show any result or evidence of the referral being completed. Staff confirmed that although the order was sent, the orthopedic provider had contacted the resident's personal cell phone instead of the unit's line, and nursing did not complete the necessary follow-up, resulting in a delay of three months before the resident was set up to be seen.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to provide residents with food at a safe and appetizing temperature, affecting four of the sixteen sampled residents. Multiple residents reported that their meals were consistently served cold, and observations confirmed that food items were not at the appropriate temperature when served. For instance, a resident received a peanut butter and jelly sandwich with wet and soggy bread, and another resident's sausage was served at 84.8 degrees Fahrenheit before reheating. Staff members were observed microwaving food without checking temperatures before or after reheating, relying on visual cues like steam to determine if the food was adequately heated. The facility's policy required that food temperatures be checked upon arrival from the main kitchen and reheated in an oven if below 140 degrees Fahrenheit. However, staff members did not adhere to this policy, as they did not consistently check temperatures or use the oven for reheating. Instead, they used microwaves, which was not in line with the facility's procedures. Staff members admitted to reheating food in the microwave primarily because surveyors were present, indicating a lack of consistent practice in maintaining food safety standards. The facility's failure to follow its policy and ensure food was served at safe temperatures led to the deficiency.
Failure to Honor Resident Preferences for Shower Frequency
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not providing residents with choices regarding the timing and frequency of showers. Three residents expressed dissatisfaction with the current shower schedule, which was not aligned with their preferences. Resident #104 reported being allowed only one shower per week, with significant gaps between showers, and expressed a desire for more frequent showers. Resident #114 also stated she received only one shower a week and wished for more, while resident #126 indicated she was scheduled for one shower a week but often went longer periods without assistance, despite needing help. The facility's documentation did not reflect any refusals or unavailability of the residents for showers, suggesting a lack of proper record-keeping. Staff interviews revealed that showers were often postponed due to other tasks or resident unavailability, but these instances were not documented. Additionally, the facility lacked a specific policy addressing shower frequency and resident preferences, contributing to the inconsistency in meeting residents' needs and preferences for personal hygiene.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing for three residents, resulting in extended periods without showers. Resident #119 was scheduled for showers twice a week, but records showed gaps of 11 and 13 days between showers. Similarly, resident #121, who was scheduled for weekly showers, experienced gaps of 10, 11, and 12 days. Resident #127, also scheduled for weekly showers, had gaps of 14, 8, and 10 days between showers. Interviews with residents #121 and #127 confirmed infrequent showers, and there was no documentation indicating that any of the residents refused or were unavailable for their scheduled showers. The facility's policy on activities of daily living (ADLs) requires that assistance with personal hygiene and bathing be provided as directed in the care plan and documented in the medical record. However, the facility did not adhere to this policy, as evidenced by the lack of documentation for refusals or unavailability and the extended periods between showers for the affected residents. This deficiency was identified through interviews and record reviews, highlighting a failure to meet the residents' needs for personal hygiene assistance.
Inadequate Care Plan for Resident with Multiple Health Concerns
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple health concerns, including skin issues, nutrition, activities of daily living (ADLs), mobility, and urinary concerns. The resident was admitted with diagnoses such as rectal ulceration, a second-degree burn on the abdomen, incomplete paraplegia, and a suprapubic catheter. Despite these significant health issues, the care plan initiated for the resident only addressed dental care and nutrition, lacking documentation for assistance with ADLs like bathing, dressing, transferring, mobility, catheter care, or wound care. Observations and interviews revealed that the resident relied on a wheelchair for mobility and required staff assistance for transfers and hygiene. Staff interviews indicated challenges in completing scheduled showers due to workload and resident availability, with no documentation of refusals or missed showers. Additionally, although the resident had skin concerns and required extra nutrition for healing, this was not reflected in the care plan. The facility's policy required a comprehensive interdisciplinary care plan within 21 days of admission, but this was not adequately developed for the resident in question.
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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