Billings Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 600 S 27th St, Billings, Montana 59101
- CMS Provider Number
- 275120
- Inspections on file
- 35
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Billings Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
The facility failed to timely report an allegation of sexual abuse and to submit investigation findings for multiple abuse-related events to the State Survey Agency. A resident with a history of inappropriate contact with female residents was observed placing his hand on another resident's thigh while assisting with feeding; a staff member intervened and reported this to a nurse, who documented the behavior but did not report it as required. In separate incidents, a verbal altercation between two residents and a resident's allegation of verbal abuse by a staff member were reported as events, but the required investigation findings were submitted to the state one day past the regulatory deadline, despite internal alerts and established abuse-reporting policies.
The facility failed to investigate an allegation of inappropriate, nonconsensual resident-to-resident contact. A behavior note documented that a resident had repeatedly entered female residents’ rooms and rubbed their legs, and specifically referenced an incident involving two residents. This event was not reported to the State Survey Agency and was not investigated, despite a facility policy requiring immediate investigation of suspected abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved parties and witnesses, and thoroughly documenting the findings.
A resident sustained first- and second-degree burns to the abdomen, groin, and hip, and nursing staff did not consistently assess, treat, and document the wounds according to professional standards. Initial notes described the burns and provider orders for daily dressings, but subsequent entries were sporadic, lacked detailed wound assessments (including measurements, classification, edges, odor, pain, and infection status), and did not address all affected areas. The wound nurse left unexpectedly, and the replacement nurse was unaware of the wound until it had already resolved. The MAR showed multiple days where ordered daily dressing changes to the hip burn were not documented as completed, contrary to the facility’s wound management policy and ANA documentation principles.
A resident with a below-the-knee amputation had their stump secured to a wheelchair footrest using a compression wrap that could not be removed independently. Staff used the wrap without a physician's order, assessment, or documentation, and there was no monitoring or evaluation of the restraint or the resident's skin. Facility policy requiring assessment and authorization for restraints was not followed.
A resident with a wound and intermittent confusion was admitted and required varying levels of assistance with activities of daily living, but no baseline care plan was completed within 48 hours as required. Staff confirmed the care plan was still blank at the time of review, despite facility policy mandating timely completion to address immediate care needs.
A resident who was missing teeth and relied on dentures did not have a care plan that accurately reflected their dental status or specific oral care needs. Staff provided inconsistent oral and denture care, and family members reported having to clean the resident's dentures themselves due to staff neglect. The facility's care plan lacked essential details, and documentation of oral care was insufficient.
A resident with a left below-knee amputation refused to wear a prescribed brace, leading staff to use a compression wrap to secure the stump to the wheelchair leg rest. The care plan was not updated to reflect the resident's refusal, the use of the compression wrap as a restraint, or related risks, despite facility policy requiring such revisions.
Multiple residents reported ongoing delays in meal service, with meals often served hours late and complaints not resulting in timely resolution. Staff confirmed dietary short-staffing contributed to the delays, and grievance documentation showed repeated concerns without evidence of prompt or effective response.
The facility did not provide timely notification to the State Long-Term Care Ombudsman regarding the transfer and discharge of three residents. Interviews and record reviews showed that required notifications were not sent, and staff responsible for this process was unaware of the requirement, resulting in missing documentation in the affected residents' charts.
Several residents experienced repeated delays in meal service, with some receiving meals hours late or having to rush to attend activities or take medications. Staff confirmed that ongoing staffing shortages contributed to the late meal delivery, and all available personnel were observed assisting with meal service in the dining room.
A resident with a suprapubic catheter experienced ongoing skin breakdown and frequent bladder infections due to inconsistent catheter care, including improper cleaning methods and failure to secure the catheter. Staff interviews revealed confusion about care procedures and lack of communication regarding the resident's condition, despite facility policies outlining appropriate catheter care and reporting requirements.
A resident with end-stage COPD experienced a severe weight loss over two months, but the facility did not follow up on a recommended re-weigh, failed to document refusals, and did not implement dietary interventions. Staff interviews confirmed inconsistent documentation and a lack of follow-up, while the nutrition at risk review system did not trigger intervention due to missing weight data.
A staff member did not perform hand hygiene before entering a resident's room and failed to wear a gown while providing suprapubic catheter care, despite an Enhanced Barrier Precautions sign indicating the need for PPE. Another staff member was initially unaware of the reason for the EBP sign until reviewing the care plan, which specified precautions for catheter care.
A resident assessed as at risk for elopement, with a high BIMS score, was able to remove her wander guard using scissors obtained from another resident and exited the facility undetected. Staff were unaware of her absence until notified by law enforcement, who found her in a nearby park approximately 45 minutes later. Documentation showed inconsistencies regarding the resident's wander guard status, and supervision measures in place did not prevent the elopement.
Multiple residents were not adequately protected from physical abuse when a resident with a history of aggressive behavior was able to repeatedly engage in altercations with others, resulting in injuries such as falls, lacerations, and bruising. Lapses in supervision and failure to follow abuse prevention protocols allowed these incidents to occur, as staff did not consistently provide required monitoring or intervene to prevent resident-to-resident conflicts.
The facility did not ensure medications were administered within the required time frame or to the correct residents, as evidenced by multiple instances of late medication administration and a medication error where one resident received another's medications. Several residents reported receiving medications late, particularly during night shifts, and audit reports confirmed repeated delays and missed doses. Facility policy requires medications to be given within one hour of the scheduled time and to the correct resident, but these standards were not consistently followed.
The facility did not maintain accurate and complete medical records for three residents involved in multiple physical altercations. After several incidents, there was no documentation in the medical records describing the events or assessing the physical and psychosocial condition of those involved, nor were interventions or responses recorded as required. Staff confirmed that such documentation should have been present, but no explanation was given for its absence.
The facility failed to store food according to professional standards, with several items found expired or lacking proper date labels. Additionally, non-food items were improperly stored on the floor, violating facility policy. A staff member acknowledged the issues but had not yet corrected them.
The facility failed to maintain a clean and safe environment for three residents, with issues such as exposed sheetrock, damaged flooring, and uncleanable surfaces. One resident's room was cluttered and dirty, with a broken electrical outlet cover and a sheet that had not been changed for weeks. Despite daily housekeeping visits, maintenance requests were not logged, and staff interviews revealed inconsistencies in cleaning practices and communication.
The facility failed to cover catheter bags for two residents, compromising their dignity. One resident was unaware of the option to cover the bag, while another expressed discomfort with the exposure. Staff acknowledged the requirement to cover bags but noted that CNAs sometimes neglected to do so. The facility did not provide a catheter care policy by the survey's end.
A resident self-administered insulin without supervision, contrary to the facility's policy requiring supervision and periodic assessment. The resident, who had been independently managing insulin and glucose levels, was not observed by nurses, and staff were unaware of the required assessment documentation. The facility's policy mandated quarterly evaluations, which were not conducted.
A facility failed to investigate a staff member accepting money from a resident for craft items, violating policy. Additionally, two residents reported missing personal items, with no specific policy in place to address such issues. Staff interviews revealed inadequate handling of grievances related to missing belongings.
A facility failed to report an abuse allegation in a timely manner when a resident was left unattended on the toilet, and another resident was transported naked in a common hallway. The initial report and investigation findings were submitted late to the State Survey Agency, violating the facility's policy on timely reporting of abuse and neglect.
A facility failed to thoroughly investigate an incident where a resident was transported naked to a shower room. The investigation lacked comprehensive documentation, including interviews with other residents and staff, and did not follow the facility's abuse policy. The incident led to one staff termination and a warning for another.
A resident who lost dentures seven years ago was not offered help to obtain new ones, leading to difficulty eating. Despite this, the MDS inaccurately indicated no dental issues. Staff involved in the MDS process were unaware of the resident's lack of dentures, and there was no formal process to ensure MDS accuracy.
The facility failed to develop baseline care plans within 48 hours for two residents, leading to deficiencies in addressing their immediate care needs. One resident's care plan was delayed, while another's lacked documentation for urinary catheter management, despite repeated tampering incidents.
The facility failed to implement comprehensive care plans for two residents, one requiring dialysis and another with dental and respiratory needs. The dialysis resident did not receive post-dialysis care, and their care plan lacked dialysis-related assessments. The second resident's care plan did not address the need for dentures or CPAP oxygen tubing changes, leading to difficulties in eating and potential respiratory issues.
A facility failed to complete an elopement evaluation for a resident at risk of elopement, who had attempted to leave the facility. The resident, with medical conditions including anoxic brain damage, was only oriented to person upon admission. Despite the resident's attempt to leave and subsequent use of a wander guard, the responsible party was not informed, leading to concerns about the resident's safety and supervision. The facility's policy required an elopement risk evaluation upon admission, which was not conducted.
A facility failed to change a resident's oxygen tubing as ordered, increasing the risk of respiratory infections. Observations revealed the tubing was dated months prior, and the resident reported it had never been changed. Staff interviews showed inconsistencies in the process and frequency of changing the tubing, with documentation in the TAR not consistently recorded, indicating a lack of adherence to protocol.
A facility failed to provide necessary pre and post-dialysis care for a resident, as staff did not take vitals or assess the access site upon the resident's return from dialysis. The resident's EHR showed no dialysis assessments since admission, and staff confirmed the absence of a care plan or physician order. This non-compliance with the facility's Hemodialysis Access Care policy posed potential harm, including hypotension, renal failure, and infection.
A certified medication aide II improperly administered subcutaneous medications, including Ozempic and glatiramer acetate, to a resident over several months. The aide was only permitted to administer prelabeled, pre-drawn insulin according to state law, but administered other subcutaneous medications, leading to a deficiency in compliance with regulations.
A resident without dentures experienced difficulty eating due to the facility's failure to address his dental needs. Despite the resident's challenges, staff did not inquire about or facilitate obtaining dentures, assuming he did not want them. The care plan noted oral health issues, but no action was taken to resolve them.
A resident undergoing dialysis experienced repeated issues with the facility's failure to accommodate his dietary preferences and intolerances. Despite clear instructions to avoid bananas, the resident was frequently given them, causing frustration. Additionally, the resident faced delays in receiving breakfast on dialysis days and reported spoiled lunches. The resident also had to retrieve his cranberry juice, which was a standing order, indicating a lapse in meeting his dietary needs.
The facility failed to provide written notices of transfer for three residents, as required. In one case, a resident's transfer notice was missing due to a shortage of forms. Another resident's transfer notice was not completed or scanned into the electronic medical record. A third resident was transferred multiple times without the necessary written notices. Staff interviews indicated that a lack of forms contributed to these deficiencies.
The facility failed to provide a Notice of Bed Hold to two residents or their representatives during hospital transfers. One resident's notice was unsigned, and another's electronic medical record lacked documentation of the notice on two occasions. Staff interviews revealed that the required process was not followed, and the facility's policy mandates providing bed hold information within one business day of an emergency transfer.
A cognitively impaired resident, at risk of elopement, was left unattended in a bathroom at a dialysis center by a facility transportation driver. The driver, lacking training for transfers, assumed medical staff were aware of the resident's presence. The resident was found hours later, having missed his dialysis appointment, and was later hospitalized for an unrelated issue.
The facility failed to maintain proper food storage and labeling practices, with undated, unlabeled, and expired items found in the kitchen's walk-in freezer and refrigerator. Staff member H admitted to lapses in monitoring due to personal absence, and there was confusion about temperature checks in resident unit areas. The facility's policy on refrigerator and freezer management was not consistently followed, contributing to the deficiencies observed.
A resident experienced significant pain due to the failure of the facility to administer HYDROcodone-Acetaminophen as ordered for chronic pain. The medication was scheduled to be given five times a day, but doses were missed, and the reasons were not documented in the MAR. The staff member responsible reported forgetting to administer the medication.
A resident's room had a damaged wall and shelf, which were not repaired despite the resident's complaints. Maintenance staff were aware of the issue and had informed nursing staff that the room needed to be vacated for repairs, but the request was not completed in the Maintenance Request Log.
Facility staff failed to ensure a PASARR document was completed for a resident who was severely cognitively impaired and receiving multiple medications. The document was requested but not provided, and a staff member indicated the resident had transferred from a closed facility, leading to a lack of access to medical records.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident who is blind and has chronic leg wounds. The resident's immediate needs, including pain management and wound care, were not documented in the EHR. The MDS nurse responsible for the care plan was no longer employed, and the facility has since changed its process to assign this task to the nurse completing the admission assessment.
A facility failed to provide meaningful activities and one-to-one interactions for a mostly bedridden and blind resident. The resident reported staying in bed due to leg pain and not participating in any activities or receiving visits from the Activities Department. A review of the resident's EHR showed a lack of timely activity assessment and care plan addressing her activity needs. A staff member acknowledged that the previous Activity Director forgot to conduct the assessment.
The facility failed to lock a storage room containing a sharp object, posing a risk to wandering residents. Additionally, a resident with mobility issues was not consistently assisted in transferring from bed to chair for meals, despite care plan instructions to prevent aspiration pneumonia. Staff interviews revealed inconsistencies in practice and documentation of the resident's transfer refusals.
A facility failed to implement a comprehensive care plan for a resident with oxygenation issues, leading to inappropriate use of ordered respiratory equipment. The resident reported that their oxygen concentrator was not functioning for two weeks, yet staff were unaware of the issue. The care plan lacked goals or interventions for the use of oxygen with BPAP at night, despite the resident's medical history of obstructive sleep apnea and other respiratory conditions. The facility's policy on oxygen administration was not followed, contributing to the deficiency.
A resident's dietary preferences were not followed by the facility's dietary staff, despite clear communication and documentation of these preferences. The resident, who disliked carrots and had standing orders for coffee with meals, reported receiving meals with carrots and having to retrieve his own coffee. Staff interviews revealed that meal slip orders were sometimes missed when staff were rushing.
The facility failed to provide written notices of transfer reasons to two residents or their representatives. One resident was hospitalized twice for sepsis and a UTI, and another was transferred after a fall and head injury. Staff indicated that administration was responsible for issuing these notices, but none were provided, contrary to facility policy.
The facility failed to provide required bed hold notices to two residents prior to hospital transfers. One resident was hospitalized twice for sepsis and a UTI, and another was transferred after a fall. Staff interviews revealed confusion about responsibility for issuing notices, and the facility's policy was not followed.
A resident was denied re-entry to a facility after leaving the hospital AMA, despite administrative instructions to allow him to stay. The resident, who was weak and recently diagnosed with cancer, was left outside in inclement weather for several hours. Staff failed to follow directives and showed a lack of concern, resulting in the resident being taken to the hospital by police.
The facility failed to report a significant event where a resident was denied reentry after leaving a hospital AMA, resulting in the resident being left outside and later taken by police. Additionally, the facility did not report findings of several incidents, including falls and abuse, to the State Survey Agency within the required timeframe. Miscommunication and lack of awareness during a change in administration contributed to these reporting failures.
Failure to Timely Report Alleged Abuse and Submit Investigation Findings
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse to the State Survey Agency (SSA) and failed to submit investigation findings for multiple abuse-related events within required timeframes. For one resident, behavior progress notes documented that the resident had repeatedly been removed from female residents' rooms and had been rubbing the legs of other female residents, with staff repeatedly correcting and educating him on inappropriate behavior. A staff member later identified that this behavior should have been reported as a reportable event to the SSA but had not been. In a specific incident, a staff member observed this resident placing his hand on another resident's thigh while assisting her with eating, asked him to remove his hand, and reported the behavior to the nurse on duty after it recurred. The nurse documented the behavior in the resident's behavior charting but did not report the allegation to the SSA, despite having received training on forms of abuse and reporting requirements. The facility also failed to submit investigation findings to the SSA within the required five working days for several previously reported events. One facility-reported event involved a verbal altercation between two residents, for which the investigation findings were due to the SSA by a specified date but were submitted one day late. Another facility-reported event involved a resident's allegation of verbal abuse by a staff member, where the investigation findings were also submitted one day past the due date. The administrator reported that an Administrator in Training was responsible for submitting reportable events and investigation findings and that alerts were received when findings were due, but could not explain why the findings were submitted late. These actions and inactions were inconsistent with the facility's Abuse, Neglect, and Exploitation policy, which required reporting allegations of abuse to appropriate agencies within specified timeframes and reporting investigation results within five working days of the incident, as required by state agencies.
Failure to Investigate Resident-to-Resident Inappropriate Contact
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of resident-to-resident inappropriate, nonconsensual contact. A behavior progress note for resident #73 dated 12/14/25 documented that this resident had repeatedly been removed from female residents’ rooms and had been rubbing the legs of other female residents. The note indicated that staff had repeatedly corrected and educated the resident on this inappropriate behavior. Despite this documentation, there was no evidence that the specific incident involving residents #46 and #73 on 12/14/25 was reported to the State Survey Agency or investigated by the facility. During an interview on 2/24/26, staff member A reported that while reviewing the former resident #73’s chart in connection with a possible return to the facility, they discovered a progress note describing a reportable event involving residents #46 and #73 that had not been reported or investigated. Staff member A stated they had not been aware of the incident prior to this chart review. Review of the facility’s incident reports confirmed that the event between residents #46 and #73 on 12/14/25 was not included among incidents reported or investigated. This failure occurred despite the facility’s written Abuse, Neglect, and Exploitation policy, which requires an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, determining whether abuse or related mistreatment occurred, and thoroughly documenting the investigation.
Inadequate Burn Wound Assessment, Treatment Documentation, and Follow-Through
Penalty
Summary
Licensed nursing staff failed to provide wound care and documentation in accordance with professional standards for a resident who sustained first- and second-degree burns to the lower abdomen, groin, and right hip after spilling hot soup. Initial documentation on the day of injury described the burn locations, sizes, and blistering, and indicated that the provider evaluated the burns and gave instructions for new orders, including dressing applications. Subsequent nursing notes on selected days documented that the burn area was cleaned, Bacitracin applied, and dressings placed, with brief comments such as "no signs of infection" and that the resident tolerated treatment. However, these notes did not consistently address all burn areas or provide detailed assessments of the wounds, including classification, measurements, wound assessment, wound edges, odor, pain, or signs of infection, nor did they evaluate whether the treatment was beneficial. Record review showed multiple dates with no wound status notes, including several days immediately following the injury and a prolonged gap until the wound was later documented as resolved. The wound management nurse had left the facility unexpectedly, and the nurse who assumed wound responsibilities reported she was unaware of the resident’s wound until weeks later, when she first assessed it and found it resolved. The Medication Administration Record for the month showed that ordered daily dressing changes to the right lateral hip burn site were not documented as completed on eight of 21 days. The facility’s own wound treatment management policy required documentation of treatments and ongoing assessment of wound effectiveness, and professional standards cited by the American Nurses Association emphasized the need for clear, accurate, and accessible nursing documentation, which were not met in this case.
Failure to Ensure Resident's Right to Be Free from Physical Restraints
Penalty
Summary
A resident with a left below-the-knee amputation was observed with their stump secured to a wheelchair footrest using a tan compression wrap, which the resident was unable to remove independently. Staff interviews revealed that the compression wrap had been used for some time to keep the stump in place because the resident would not wear their prescribed brace. Multiple staff members acknowledged that there was no physician's order for the use of the compression wrap as a restraint, and no assessment or documentation was completed regarding its use. Staff also indicated a lack of awareness about the need for documentation or assessment, and some staff were under the impression that securing the stump in this manner was permissible. Record reviews confirmed the absence of a physician's order, assessment, or documentation related to the use of the compression wrap as a restraint. There was no evidence of monitoring, release, or skin assessment for the area where the wrap was applied. Additionally, therapy evaluations did not address the use of the compression wrap for stump positioning. The facility's own policy prohibits the use of physical restraints without proper assessment, documentation, and physician authorization, none of which were present in this case.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident, who had a wound and experienced forgetfulness and confusion, was observed at the nursing station wearing soiled clothing and reported needing assistance with dressing and hygiene. Documentation showed that the resident's needs for activities of daily living varied, requiring different levels of assistance, but no baseline care plan was in place to address these needs within the mandated period. Interviews with staff confirmed that a baseline care plan had not been completed for the resident, and at the time of the survey, the care plan in the electronic medical record was still blank. The facility's policy required that a baseline care plan be developed and implemented within 48 hours of admission, including essential healthcare information to properly care for the resident. The lack of a timely baseline care plan had the potential to affect all new admissions.
Failure to Develop and Implement Comprehensive Oral Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan that adequately assessed and addressed the dental status and oral care needs of a resident. Observations revealed that the resident was lacking teeth and relied on dentures, which had been lost by the facility and replaced by an old pair provided by family. Interviews with staff indicated inconsistent practices regarding oral and denture care, with some staff believing that if dentures were already in place, oral care was unnecessary. The resident's care plan did not specify whether the resident had no teeth or dentures, nor did it outline the specific type of oral care required. Further interviews with family members revealed that the facility had not replaced the lost dentures as expected, and that family members had to clean the resident's dentures themselves due to staff neglect. The facility's policy required comprehensive, person-centered care plans that included resident-specific interventions, but the care plan for this resident lacked essential details about dental status and oral care needs. Documentation and communication regarding refusals of care and the resident's oral health status were also found to be insufficient.
Failure to Revise Care Plan After Resident Refusal and Use of Restraint
Penalty
Summary
The facility failed to revise a resident's care plan after the resident refused to wear a prescribed brace and staff began using a compression wrap to secure the resident's left below-knee amputation stump to the wheelchair leg rest. Observations showed the resident was unable to remove the compression wrap and was seen pulling at it. Staff interviews revealed that the use of the compression wrap was not documented in the care plan, and refusals of the brace were not consistently recorded or reported. Staff also indicated that the use of the compression wrap had been ongoing and was not based on a documented care plan intervention. Review of the resident's comprehensive care plan showed no updates or interventions related to the use of the compression wrap as a restraint or the resident's refusal to wear the brace. The care plan only referenced the brace and monitoring under it, with no mention of the alternative intervention or associated risks. Facility policies required the care plan to be reviewed and revised by the interdisciplinary team and updated to reflect any restraint use, but these steps were not followed for this resident.
Failure to Resolve Resident Grievances Regarding Delayed Meal Service
Penalty
Summary
The facility failed to resolve resident grievances in a timely manner regarding delayed meal service, as evidenced by multiple residents reporting consistent and significant delays in receiving their meals. Observations and interviews revealed that meals were often served two or more hours late, with residents stating that their complaints did not result in any changes. Staff interviews confirmed that the dietary department was short-staffed, leading to prolonged wait times for meals. Residents reported that the delays had been ongoing for months and that their concerns were not addressed or communicated back to them. Review of facility grievance forms documented repeated complaints about late meals and lack of consistency in meal service. The forms indicated that residents were waiting over an hour for meals and that the kitchen was short-staffed, causing delays. Despite these documented grievances, the facility did not provide evidence that residents were kept informed of progress toward resolution or that prompt efforts were made to resolve the issues, as required by facility policy. Posted mealtimes were not adhered to, further supporting the deficiency in timely grievance resolution.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide timely notification to the State Long-Term Care Ombudsman regarding the transfer and discharge of three residents. Interviews revealed that the ombudsman had not received any transfer or discharge notifications from the facility, despite having previously requested such notifications. Staff responsible for the notifications was unaware of the requirement and had not been sending the necessary information to the ombudsman. Record reviews confirmed that the medical charts for the affected residents did not contain evidence that the required notifications had been made at the time of their transfer or discharge. Specifically, one resident was transported to the Emergency Department, admitted to the hospital, and later returned to the facility, but there was no documentation of ombudsman notification. Two other residents were discharged from the facility, and their charts also lacked evidence of notification to the ombudsman. The deficiency was identified through interviews with staff and the ombudsman, as well as a review of resident records and facility correspondence.
Failure to Provide Timely Meal Service Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide sufficient support personnel to ensure that meals were served to residents in a timely manner, as required by posted mealtimes. Multiple residents reported that meals were consistently late, with one resident stating that lunch was just being served at 2:15 p.m., well after the scheduled time. Another resident expressed frustration at having to rush through breakfast to attend church, while a different resident noted receiving evening medications before dinner due to the meal being delayed. Several residents indicated that late meals caused them to miss or rush through activities, and one resident specifically mentioned that dinner had been served as late as 7:00 p.m. over the past two months. Residents also reported that staffing shortages were a persistent issue and that grievances about the problem had not led to improvements. Staff interviews during a resident council meeting confirmed that meal delays were related to staffing concerns. One staff member acknowledged ongoing hiring attempts that had not resolved the issue, and another encouraged residents to eat in the dining room for faster service, as meal delivery to rooms was slower. Observations confirmed that all available staff were assisting with breakfast tray service in the dining room, further indicating a lack of adequate support personnel to meet the needs of all residents in a timely manner.
Failure to Provide Proper Suprapubic Catheter Care and Maintenance
Penalty
Summary
Staff failed to provide proper suprapubic catheter care and maintenance for a resident, resulting in an unidentified and untreated skin breakdown around the catheter insertion site. The resident reported that catheter care was inconsistently performed, with cleaning occurring only about every other brief change, and that staff often used alcohol wipes instead of the facility-approved cleanser or mild soap and water. The resident also noted frequent bladder infections, leakage, and that the catheter was not consistently secured to prevent pulling, which contributed to skin redness and maceration. During observations, staff were seen using alcohol wipes to clean the catheter and insertion site, and the catheter was not secured afterward. Redness and maceration the size of a nickel were observed around the insertion site, and the resident stated this condition was ongoing and worsened when the catheter was not secured. Interviews with staff revealed a lack of clarity regarding the specific cleaning procedures and products to use for suprapubic catheter care, with some staff unaware of the resident's care orders or the presence of skin breakdown. Documentation in the care plan and facility policy indicated that staff should inspect the insertion site for signs of infection, use approved cleansers, and secure the catheter to prevent pulling. However, these procedures were not consistently followed, and communication lapses were evident, as some nurses were not informed of the skin breakdown. The failure to adhere to established catheter care protocols and to report and address skin issues led to the deficiency.
Failure to Address Severe Weight Loss and Document Interventions
Penalty
Summary
The facility failed to adequately address a severe weight loss in one resident by not following up on a recommended re-weigh, failing to document refusals, and not implementing dietary interventions. The resident's weight records showed a significant drop of over 10% within two months, with missing or refused weights documented for several months. Despite a registered dietitian noting dramatic weight loss and recommending a re-weigh, there was no follow-up documentation or evidence of further dietary intervention. Additionally, the resident's treatment administration record and nursing progress notes lacked consistent documentation of weight refusals or actions taken. Interviews with staff revealed that the resident frequently refused to be weighed and had a history of frustration with weight monitoring, especially after previous hospice care. Staff acknowledged that without a current weight, the nutrition at risk review system did not flag the resident for intervention. The resident, who had end-stage COPD and was on hospice, reported difficulty eating due to shortness of breath. No nutrition at risk meeting notes were available for the period in question, and the facility's tracking system failed to ensure appropriate follow-up for the resident's weight loss.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
Staff failed to follow proper infection control practices during suprapubic catheter care for a resident. Specifically, a staff member entered the resident's room without performing hand hygiene, touched items in the room, and then exited to perform hand hygiene only after contact had already occurred. The same staff member performed suprapubic catheter care without wearing a gown, despite the presence of an Enhanced Barrier Precautions (EBP) sign on the resident's door, which indicated the need for gown and glove use during high-contact care activities such as catheter care. Another staff member was unaware of the reason for the EBP sign until reviewing the resident's care plan, which confirmed it was related to the suprapubic catheter. Facility policy required the use of gowns and gloves for such care to reduce transmission of multidrug-resistant organisms.
Resident Elopement Due to Inadequate Supervision and Wander Guard Removal
Penalty
Summary
A resident with a high Brief Interview for Mental Status (BIMS) score of 13, who was assessed as being at risk for elopement and wandering, was able to remove her wander guard by cutting it off with scissors obtained from another resident. The resident then exited the facility through the main doors without staff knowledge and was later found by local law enforcement in a park across the street. The incident report indicated that staff were not aware of the resident's absence until notified by police, at which point the resident had been missing for approximately 45 minutes. Review of facility documentation showed that the resident's most recent Minimum Data Set (MDS) did not indicate she was wearing a wander guard, despite a prior risk assessment identifying her as at risk for elopement. Staff interviews revealed that the resident was new to the facility, enjoyed social activities, and was generally supervised through hourly rounds and 15-minute checks following the incident. The facility's monitoring and supervision failed to prevent the resident from obtaining scissors, removing her wander guard, and leaving the premises undetected.
Failure to Prevent and Monitor Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect multiple residents from abuse and neglect, specifically in cases involving resident-to-resident altercations. On several occasions, one resident with a history of intrusive and aggressive behaviors was able to physically engage with other residents, resulting in injuries. In one incident, this resident approached another in a common area, grabbed him by the shirt, and pulled him from his wheelchair, causing both to fall to the ground. The victim was not exhibiting any provoking behaviors at the time of the incident. Further review revealed that the same resident entered another resident's room on two separate occasions, leading to physical altercations. In one instance, the resident entered a shared room, approached a roommate, and was physically removed by another resident, resulting in a fight. In another incident later that night, after being put to bed and no longer under one-to-one supervision, the resident again entered the same room, leading to a physical confrontation that caused visible injuries, including a laceration near the eye and chest bruising to one of the residents involved. Staff interviews confirmed lapses in supervision, with one staff member noting that the assigned one-to-one monitor was not present when the resident left his bed. The facility's policy required increased supervision and ongoing assessment for residents with behaviors that may lead to conflict, but these measures were not consistently implemented. The lack of adequate monitoring and failure to maintain a safe environment directly contributed to repeated altercations and injuries among residents, demonstrating a breakdown in the facility's abuse prevention protocols.
Failure to Administer Medications Timely and to Correct Residents
Penalty
Summary
The facility failed to ensure that medications were administered within the required time frame and to the correct residents, as evidenced by multiple instances of late medication administration and medication errors. Several residents reported receiving their medications late, particularly during night shifts and weekends. Medication Administration Audit Reports for multiple residents showed that medications were often given well outside the one-hour window before or after the scheduled administration time, with some doses being missed entirely or administered several hours late. In addition to late administration, there were documented cases where a resident was given another resident's medications. Specifically, one resident received evening medications intended for another resident, including melatonin, memantine, tamsulosin, and trazodone, in addition to their own prescribed medications. This error was noted in the nursing progress notes, and the affected resident reported feeling excessively sleepy and slept late the following day. The records did not clarify whether the resident who was supposed to receive those medications actually received the correct doses. The facility's policies on medication administration and medication errors require adherence to the six rights of medication administration, including the right resident and right time, and specify that medications should be administered within 60 minutes of the scheduled time. Despite these policies, the audit reports and interviews confirm that these standards were not consistently met for several residents over multiple days, resulting in both late and incorrect medication administration.
Failure to Document Resident Altercations and Assessments in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents involved in multiple altercations. Specifically, after a reported incident where one resident was pulled from a wheelchair by another, there was no documentation in the medical records of either resident describing the incident or assessing their physical and psychosocial condition. Additionally, there was no record of interventions implemented to protect the residents or the response to those interventions. In a subsequent incident involving the same resident as the aggressor and two other residents as victims, the medical record for one of the victims did not include a description of the incident or an assessment of their condition following the altercation. A third altercation occurred later the same day, resulting in injuries to one resident, but the nursing progress notes again failed to document the incident or the resident's condition immediately after. The only related note appeared the following day, describing the injuries but not the circumstances of the altercation. Staff interviews confirmed that each resident involved in such incidents should have corresponding documentation in their medical records, but no explanation was provided for the lack of progress notes regarding these events.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey. Various food items in the kitchen storage were found to be improperly labeled or expired. Specifically, open containers of Worcestershire sauce, chili powder, Tuscan dressing, and other items were either expired or lacked proper dating. Additionally, several food items such as pancake mix, parsley flakes, and pepperoni were open without any date labels. This lack of proper labeling and dating of food items indicates a failure to adhere to the facility's policy on food storage, which requires all food to be labeled and dated with an appropriate use-by date. Furthermore, the facility was found to be storing non-food items improperly. Cases of coffee lids, foam containers, portion cups, dinner napkins, and other paper goods were stored on the floor in the hallway and closet, contrary to the facility's policy that requires food and related items to be stored at least six inches off the floor. During an interview, a staff member acknowledged awareness of these issues and mentioned plans to address them, but at the time of the survey, the deficiencies remained uncorrected.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for three residents, resulting in deficiencies in their living conditions. Resident #28's room had a significant tear in the sheetrock, exposing powdered sheetrock and creating an uncleanable surface. Additionally, the bathroom paint was peeling around the toilet, further contributing to the unsanitary conditions. Resident #28 expressed dissatisfaction with the state of her room, indicating awareness of the issue. Resident #72's bathroom floor had a large hole in the linoleum, with worn edges that had discolored over time. The bathroom walls also had multiple areas where the sheetrock was exposed, creating additional uncleanable surfaces. Despite these issues, there were no maintenance requests logged for repairs in either resident #28 or #72's rooms, indicating a lack of action from the facility to address these concerns. Resident #29's room was observed to be dirty and cluttered, with stained floors and a broken electrical outlet cover. The resident's bed had a dirty, threadbare sheet that had not been changed for two to three weeks, despite daily housekeeping visits. Staff interviews revealed inconsistencies in cleaning practices and communication regarding maintenance needs. The maintenance staff acknowledged challenges in keeping up with repairs and noted that room audits were conducted monthly, but no maintenance requests were documented for resident #29's room issues.
Failure to Cover Catheter Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity by not covering catheter bags for two residents. During observations, one resident's catheter bag was attached to the bed and uncovered, with visible yellow urine. The resident was unaware that covering the bag was an option. Another resident's catheter bag was also exposed, and she expressed discomfort with it being uncovered. Interviews with staff members revealed that they were aware of the requirement to cover catheter bags for dignity, but noted that CNAs sometimes did not take the time to find covers. Despite requests, the facility did not provide a policy and procedure for catheter care, including the use of catheter bag covers, by the end of the survey.
Failure to Supervise Self-Administration of Insulin
Penalty
Summary
The facility failed to supervise the self-administration of insulin for one resident, increasing the risk of a negative outcome if the medication and monitoring were not handled properly. The resident, who had been self-administering insulin and monitoring blood glucose levels independently for years, reported that nurses did not observe him during these activities. The resident demonstrated the use of a continuous glucose monitoring system and stated that he informed the nurses of his blood glucose levels when asked. Staff interviews revealed that the facility lacked a documented self-administration of medication assessment for the resident. Although there was a policy in place requiring periodic reevaluation of a resident's ability to self-administer medications, staff members were unsure of the assessment's location or documentation. The resident's Medication Self-Administration Safety Screen indicated that self-administration should occur with supervision, yet no such supervision was provided. The facility's policy also required quarterly checks during MDS reviews, which were not documented for this resident.
Deficiencies in Handling Resident Belongings and Financial Transactions
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident involving a staff member accepting money from a resident in exchange for craft items. Resident #41 expressed concern about a staff member who brought in craft supplies and accepted nearly fifty dollars from her, despite the facility's policy prohibiting staff from accepting money from residents. The resident reported the incident to the administrator, but no formal documentation or investigation was conducted at the time. Staff member U admitted to accepting money from residents for supplies and was previously informed by the administration that such actions were not allowed. Additionally, the facility did not adequately address the issue of missing personal items for residents #37 and #280. Resident #37 reported that several personal items, including marking pens and clothing, had gone missing, despite filing grievances. Resident #280 also reported a significant reduction in personal clothing since admission to the facility. Staff interviews revealed a lack of a specific policy for handling missing items, and the facility's grievance policy did not effectively address the residents' concerns. The facility's documentation indicated that employees are not permitted to accept tips or gifts from residents and that personal financial transactions with residents are prohibited. However, the lack of a formal investigation and documentation of the incidents involving resident #41 and the missing items for residents #37 and #280 highlights deficiencies in the facility's handling of resident belongings and financial transactions.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report an abuse allegation involving a resident who was left unattended on the toilet by a CNA, believing another CNA would assist the resident. The incident occurred at 7:30 p.m., and the resident was later found crying in her room. The initial report of the alleged neglect was not submitted to the State Survey Agency until two days later. The final report indicated that a staff member was terminated for failing to report the incident to the facility abuse coordinator. In another incident, a resident was transported naked and uncovered from his room to the shower room by staff, which was captured on video footage. The facility's investigation findings were submitted a day late to the State Survey Agency. The facility's policy requires that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but no later than two hours if serious bodily injury is involved, or within 24 hours if not. The delay in reporting and submitting findings indicates a failure to adhere to these reporting timelines.
Incomplete Investigation of Resident Incident
Penalty
Summary
The facility failed to conduct a complete investigation of a reported incident involving a resident who was transported naked and uncovered to a shower room by staff. The incident, which occurred on 12/30/24, was reported, and one staff member was terminated while another received a final written warning. However, the facility did not maintain thorough documentation of the investigation process. The documentation provided included only two written statements from staff who learned of the incident from the resident and an unlabeled document with minimal information about the staff member who received a warning. The facility's investigation was incomplete as it did not include interviews with other residents and staff members to gather additional details or identify patterns of behavior, as initially stated in the incident description. Furthermore, the facility did not provide documentation of any care plan review or ongoing monitoring of the resident's emotional and physical health. The facility's policy on abuse investigations requires the administrator or designee to conduct interviews and document summaries, but this was not adequately followed, and the results were not reported to the State Survey Agency within the required timeframe.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to accurately assess the dental needs of a resident during the comprehensive Minimum Data Set (MDS) assessment. The resident, who lost his dentures seven years ago, reported not being offered assistance to obtain new dentures. During an observation, the resident was unable to chew a piece of broccoli and expressed difficulty eating certain foods without dentures. Despite these issues, the resident's readmission screening assessment inaccurately reflected that he had upper and lower dentures that fit, and the MDS indicated no problems with chewing. Staff member M, who was involved in the MDS admission process, stated that the resident was screened for dental needs during admission and most recently six weeks prior, with no issues noted. However, she was unaware of the resident's lack of dentures. The facility's policy on resident assessment emphasizes the importance of accurately describing a resident's capabilities and impairments to plan appropriate care. The lack of a formal process for ensuring MDS accuracy contributed to the oversight in assessing the resident's dental needs.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, leading to deficiencies in addressing their immediate care needs. Resident #75 was admitted to the facility, but the baseline care plan was not completed until several days later. Interviews with staff members revealed that nursing staff were responsible for completing these care plans, but there was no clear explanation for the delay in Resident #75's case. Resident #282, who had a history of acute kidney failure and urinary retention, was observed with a urinary catheter but lacked documentation in the care plan regarding its use. The resident had repeatedly tampered with the catheter, leading to multiple changes. Despite these incidents, the care plan did not reflect the necessary interventions to manage the catheter effectively. The facility's policy required a baseline care plan to be developed within 48 hours of admission, which was not adhered to in these cases.
Failure to Implement Comprehensive Care Plans for Dialysis and Dental/Respiratory Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident requiring dialysis, leading to a lack of post-dialysis care. Despite the resident attending dialysis sessions three times a week, staff did not take vital signs, assess the dialysis site, or perform any post-dialysis checks. The resident's electronic health record (EHR) showed no dialysis assessments since admission, and the comprehensive care plan did not include dialysis care. Staff were unable to locate any care plan or physician orders related to dialysis, despite the resident having been on dialysis since before admission. Another resident's care plan failed to address dental and respiratory needs. The resident used a CPAP machine with oxygen tubing that had not been changed since the previous year, and staff did not check the equipment. The resident also had difficulty eating due to the absence of dentures, which was not addressed in the care plan. Staff interviews confirmed that these needs were not documented in the resident's assessments or care plan, leading to inadequate care for the resident's respiratory and dental needs.
Failure to Complete Elopement Evaluation for At-Risk Resident
Penalty
Summary
The facility failed to complete a thorough elopement evaluation for a resident who was at risk of elopement and had attempted to leave the facility. The resident, who was only oriented to person upon admission, had pertinent medical diagnoses including anoxic brain damage, acute kidney failure, and urinary retention. Despite these conditions, there was no wander/elopement risk evaluation found in the resident's electronic medical record. The resident had attempted to leave the facility, and a wander guard device was subsequently ordered for safety, but the responsible party was not notified of this measure. Interviews and record reviews revealed that the resident's responsible party was concerned about the lack of supervision and the resident's safety, especially after the resident had two falls and attempted to leave the facility within two weeks of admission. The facility's policy required a wander/elopement risk evaluation for all residents upon admission, which was not completed in this case. This oversight led to the responsible party's worry about the resident's safety and the adequacy of supervision provided by the facility.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to change the oxygen tubing for a resident as ordered, which had the potential to increase the risk of respiratory infections. During multiple observations, the resident's oxygen tubing was found to be dated several months prior, indicating it had not been changed as per the facility's policy or the physician's order. The resident, who used a CPAP machine at night, reported that no one had checked or changed his oxygen tubing since he began using it. Interviews with staff revealed inconsistencies in the process of changing and tracking oxygen tubing. Staff members provided conflicting information about the frequency and responsibility for changing the tubing, with some stating it should be changed every 30 days, while others mentioned every two weeks. The facility's policy required oxygen tubing to be dated and labeled when new tubing is applied and changed weekly or according to the physician's order. However, documentation in the resident's Treatment Administration Record (TAR) showed that the tubing change was not consistently recorded, highlighting a lack of adherence to the established protocol.
Failure to Provide Pre and Post-Dialysis Care
Penalty
Summary
The facility failed to provide necessary pre and post-dialysis care for a resident receiving dialysis, which was identified during an observation, interview, and record review. The resident, who had been on dialysis since November 11, 2024, reported that staff did not take her vitals upon returning from dialysis, did not assess her access site, and no nurse checked on her post-dialysis. A review of the resident's electronic health record (EHR) showed no dialysis assessments had been completed since her admission on January 3, 2025. Staff member C confirmed the absence of a care plan, post-dialysis assessments, or a physician order in the EHR. The facility's policy on Hemodialysis Access Care, dated December 19, 2016, requires documentation of the presence of bruit and thrill every shift and completion of pre and post-assessment sections on the dialysis communication form. However, staff member B outlined that the procedures were not followed, as the nurse did not complete the necessary dialysis assessment upon the resident's return. This lack of adherence to the facility's policy and procedures resulted in a potential for harm, including hypotension, renal failure, and infection at the access site.
Improper Administration of Subcutaneous Medications by Certified Medication Aide II
Penalty
Summary
The facility failed to ensure that scheduled subcutaneous medications were administered by staff licensed to do so, affecting one resident out of a sample of 29. A certified medication aide II administered prefilled subcutaneous medications, including Ozempic and glatiramer acetate, over several months. The facility's staff member D acknowledged that the medication aide II was only permitted to administer prelabeled, pre-drawn insulin subcutaneously according to the Montana Code Annotated 2023. Despite this, the medication aide II administered Ozempic injections 17 times over five months and glatiramer acetate injections 135 times over six months. The facility's job description for a certified medication aide II indicated that they could deliver routine oral, inhalation, and topical medications under the supervision of a licensed nurse unless otherwise allowed by state law. However, the Montana Code Annotated 2023 specifies that a medication aide II may not administer parenteral or subcutaneous medications except for prelabeled, pre-drawn insulin. This discrepancy led to the improper administration of subcutaneous medications by a certified medication aide II, which was not in compliance with state regulations.
Failure to Address Resident's Denture Needs
Penalty
Summary
The facility failed to meet the oral health needs of a resident, who had been without dentures throughout his residency. The resident expressed difficulty in eating certain foods, such as overcooked meat and undercooked vegetables, due to the lack of dentures. Despite these challenges, the staff had not inquired about the resident's need for dentures, nor had they facilitated the process for obtaining them. The resident's care plan indicated the presence of oral/dental health problems, yet there was no follow-up to address these issues. Interviews with staff revealed a lack of proactive measures in assessing and addressing the resident's dental needs. Staff members assumed the resident did not want dentures because he had not explicitly requested them. The responsibility for scheduling dental appointments was placed on the resident, with staff stating that dental care was discussed during admission and readmission assessments. However, there was no evidence that the resident's need for dentures was adequately assessed or addressed in his care plan, leading to a deficiency in providing necessary dental care.
Failure to Accommodate Dietary Preferences for Dialysis Resident
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences and intolerances, specifically for a resident undergoing dialysis. On multiple occasions, the resident was provided with bananas despite a clear note on the breakfast diet slip indicating 'ABSOLUTELY NO BANANA.' The resident expressed frustration over receiving bananas with breakfast, which he did not want due to his dialysis treatment. Additionally, the resident reported that his breakfast was sometimes delayed on dialysis days, preventing him from eating before his treatment. Furthermore, the lunches provided were reportedly spoiled by the time he could consume them during dialysis. The resident also experienced issues with receiving cranberry juice, which was a standing order on his diet slip. On one occasion, the resident had to retrieve the juice himself, expressing frustration over the oversight. Staff member O stated that she followed the meal ticket for the resident's allergies, preferences, and dislikes, and mentioned that the dietitian occasionally made changes. However, the resident's care plan, which focused on dialysis, indicated that he should receive an appropriate diet lunch before leaving for dialysis, a requirement that was not consistently met.
Failure to Provide Written Notice for Transfers
Penalty
Summary
The facility failed to provide written notice of the reason for a facility-initiated transfer to three residents or their representatives. For one resident, there was no documentation of a Notice of Transfer in the electronic medical record, and the facility was unable to provide this documentation upon request. Staff interviews revealed that the facility had run out of transfer forms during the time of the resident's transfer, which contributed to the lack of documentation. Another resident was transported to the hospital for an acute change in condition, but the medical record did not show that the required written notice was provided. A staff member indicated that the notice should have been completed and scanned into the electronic medical record, but it was not. Similarly, a third resident was transferred to the hospital on multiple occasions, but the facility failed to provide the necessary written notices for these transfers. Staff interviews suggested that a shortage of forms may have been a factor in the failure to complete the notices.
Failure to Provide Notice of Bed Hold for Hospital Transfers
Penalty
Summary
The facility staff failed to provide a Notice of Bed Hold to two residents or their representatives, which is a requirement when residents are transferred to a hospital or take therapeutic leave. In the case of one resident, the Bed Hold Notice dated December 22, 2024, was not signed by either the resident or their representative. During an interview, a staff member indicated that the Notice of Bed Hold should be signed by someone, either a Power of Attorney (POA) or verbally over the phone, but this was not done for the resident in question. For another resident, the electronic medical record did not show that a Notice of Bed Hold was provided on two separate occasions when the resident was transferred to a hospital. A staff member stated that the Notice of Bed Hold should be completed by a nurse and scanned into the resident's electronic medical record, but this was not done for the resident's transfers on September 24, 2024, and December 11, 2024. The facility's policy requires that information concerning the bed hold policy be provided within one business day of an emergency transfer, but no documentation was available to confirm compliance with this policy.
Resident Left Unattended at Dialysis Center
Penalty
Summary
A facility staff member failed to ensure the safety and supervision of a cognitively impaired resident who was at risk of elopement during transport to a dialysis appointment. The resident, who required supervision due to severe cognitive impairment and poor safety awareness, was left unattended in a bathroom at the dialysis center by the transportation driver. The driver, who was not trained to assist with transfers, left the resident in the bathroom and exited the building, assuming that the medical staff was aware of the resident's presence because they had unlocked the door remotely. The resident was discovered in the bathroom by dialysis center staff approximately four hours later, having missed his dialysis appointment. The resident was calm and was transported back to the facility without any reported injuries. However, due to the missed appointment, the resident required further medical evaluation and was subsequently hospitalized for an unrelated inner ear infection. The incident highlighted a failure in communication and supervision protocols, as the resident's care plan clearly indicated the need for supervision during transport and appointments.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices, as observed during a survey. In the kitchen's walk-in freezer, several food items were found undated, unlabeled, and expired, including a pork chop with freezer burn, a tray of cod, and various other food items such as soup, tortilla shells, and gluten-free pasta. Additionally, the walk-in refrigerator contained items like bacon, margarine spray, and apricot preserves that were either undated or past their use-by dates. The dry goods storage also had issues, with unlabeled white powder and moldy sweet potatoes. Staff member H, responsible for checking food expiration dates, admitted to lapses in monitoring due to a personal absence. She acknowledged that kitchen staff were educated on labeling and dating food but noted issues with labels not being removed during dishwashing. Furthermore, there was confusion about who was responsible for checking refrigerator and freezer temperatures in the resident unit areas, leading to inconsistent temperature monitoring. The facility's policy on refrigerator and freezer management was not adhered to, as evidenced by missing temperature logs for several days in August and September. Kitchen audits conducted by staff member H revealed ongoing issues with expired foods and improper labeling, despite some corrective actions being taken. The facility's policy required daily temperature checks and proper food labeling, but these procedures were not consistently followed, contributing to the deficiencies observed.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide pain medication as ordered to relieve chronic pain for a resident, resulting in the resident voicing pain. The incident involved a resident who was prescribed HYDROcodone-Acetaminophen to be administered five times a day for chronic pain. On August 6, 2024, the 1:00 a.m. dose was held, and the 5:00 a.m. dose was not administered as scheduled. The facility's investigation revealed that the staff member responsible for administering the medication forgot to give it. The resident's Medication Administration Record (MAR) did not document the reasons for the missed doses, and the resident reported experiencing significant pain due to the missed medication.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for a resident, as evidenced by a damaged wall and shelf in the resident's room. The resident expressed dissatisfaction with the condition of her room, specifically mentioning a wall that needed repair. An observation revealed a horseshoe-shaped metal rail attached to the resident's bed, which was in contact with the wall, causing a jagged crack and a large hole. Additionally, a red shelf behind the resident's headboard was cracked and broken, creating a large gap. Staff indicated that maintenance was aware of the issue and had informed nursing staff about a month prior that the room needed to be vacated for repairs. However, the maintenance request was not acknowledged or completed in the facility's Maintenance Request Log.
Missing PASARR Document for a Resident
Penalty
Summary
Facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) document was completed for one of the sampled residents. The resident in question was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 2, and had been receiving anti-psychotic, anti-anxiety, and anti-depressant medications during the assessment period. The PASARR document was requested on September 11, 2024, but was not provided by the end of the survey. During an interview, a staff member indicated that the facility was unable to locate the PASARR for the resident, who had transferred from a closed facility previously owned by a different company, resulting in a lack of access to the resident's medical records.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop, implement, and document a baseline care plan within 48 hours of admission for one of the sampled residents, identified as resident #57. This deficiency was identified through observation, interview, and record review. Resident #57, who is blind and requires assistance with eating, reported experiencing leg pain and having chronic wounds on her legs since her 20s. Despite these needs, the electronic health record (EHR) showed no documentation of a baseline care plan, which should have been completed by August 1, 2024, following her admission. The absence of this plan meant that the resident's immediate care needs, such as pain management and wound care, were not addressed promptly. During an interview, a staff member revealed that the MDS nurse, who was responsible for initiating the baseline care plan at the time of admission, was no longer employed at the facility, and the plan was not completed. The facility has since changed its process, assigning the responsibility of initiating the baseline care plan to the nurse completing the admission assessment.
Failure to Provide Meaningful Activities for Bedridden Resident
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities and one-to-one activities for a resident who was mostly bedridden and blind. During an observation and interview, the resident expressed that she was blind and stayed in bed most of the time due to leg pain. She was unable to recall participating in any activities or having any one-to-one visits from the Activities Department. The resident mentioned that she only left her room to go to the dining room for meals and did not remember any staff offering in-room activities. A review of the resident's electronic health record (EHR) revealed that she was admitted to the facility on an unspecified date, but there was no activity assessment completed until several days after the observation. The EHR also showed that the resident had not been invited to or attended any activities, except for a single special event. Additionally, there was no care plan addressing the resident's activity needs. A staff member admitted that the previous Activity Director forgot to conduct the activity assessment, and the current Activity Director was unavailable for an interview.
Failure to Secure Hazardous Area and Assist Resident with Meal Transfers
Penalty
Summary
The facility failed to ensure a safe environment by not keeping a storage room locked, which contained a sharp object resembling a putty knife. This was observed on two separate occasions, despite staff members stating that the door should always be locked to prevent access by wandering residents. Interviews with staff members revealed a lack of consistent practice in securing the storage room, which posed a potential risk for residents who might wander into the area. Additionally, the facility did not adequately assist a resident with significant medical conditions, including an acquired absence of the left leg above the knee and difficulty walking, in transferring from bed to chair for meals. This was necessary to prevent aspiration pneumonia. Despite the care plan indicating the need for a Hoyer lift and two staff members for transfers, the resident was not consistently moved to a chair for meals. Staff interviews indicated that the resident had refused transfers in the past, but there was no clear documentation of these refusals, and the resident expressed a desire to be more comfortable in a chair during meals.
Failure to Implement Comprehensive Care Plan for Oxygen and BPAP Use
Penalty
Summary
The facility failed to implement a comprehensive resident-centered care plan for a resident with oxygenation issues, specifically regarding the use of oxygen and BPAP at bedtime. During an observation, it was noted that the resident's oxygen concentrator was not functioning for the past two weeks, and the resident reported wearing the BPAP mask at night without the concentrator working. Despite the resident's report, staff member B was unaware of any issues with the resident's oxygen equipment, indicating a lack of communication during shift change reports. The resident's care plan, revised in July 2024, did not include goals or interventions for the use of oxygen with BPAP at night, nor did it address any precautions related to oxygen use. The resident's medical history includes obstructive sleep apnea, acute respiratory failure with hypoxia, and morbid obesity with alveolar hypoventilation. The treatment administration record showed an order for BPAP settings with oxygen at bedtime, but the care plan failed to reflect this. The facility's policy on oxygen administration requires reviewing the care plan for special needs and assessing the resident while receiving oxygen therapy, but these steps were not followed. The deficiency was identified through observations and interviews, revealing a gap in the facility's adherence to its own policies and procedures for safe oxygen administration.
Failure to Follow Resident Dietary Preferences
Penalty
Summary
The dietary staff at the facility failed to adhere to the person-centered dietary preferences of a resident, who had clearly communicated his preferences and dislikes to the staff. The resident's meal slip, which included standing orders for coffee, milk, and orange juice with each meal, also listed carrots as a disliked food. Despite this, the resident reported that he frequently had to retrieve his own coffee because it was not provided with his meals, and he continued to receive meals containing carrots. The resident had informed the dietary staff about these issues, but his preferences were still not followed. Interviews with staff members revealed that the dietary staff were aware of the resident's meal slip orders and preferences, but these were sometimes overlooked when staff were rushing. One staff member admitted to preparing the resident's tray too quickly, resulting in the inclusion of carrots despite the resident's expressed dislike. The resident's care plan indicated that he was capable of communicating his needs and that staff were expected to actively listen and validate communication to ensure understanding, yet this was not effectively implemented in practice.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide written notice of the reason for facility-initiated transfers to two residents or their representatives. Resident #4 was hospitalized twice in May 2024 for sepsis and a UTI, but the electronic health record (EHR) did not contain the required written notice of the reasons for these transfers. During interviews, staff members indicated that the responsibility for completing the transfer notice lay with someone in administration, and there was no specific form used to notify residents or their representatives of the transfer reasons. Despite requests for the written notices, none were provided by the end of the survey. Similarly, resident #47 was transferred to an acute hospital after a fall and head injury on August 3, 2024, but the facility did not provide a Notice of Transfer/Discharge to the resident or their representative. Staff member E confirmed that the notice had not been provided by the nurse at the time of transfer and reiterated that administration was responsible for issuing such notices. The facility's policy on discharging/transferring residents, last revised in December 2019, requires that a Notice of Discharge/Transfer be provided, explaining the reason for the transfer, the effective date, and information on how to appeal the decision.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide the required bed hold notice to residents or their representatives prior to transfer to a hospital, as evidenced in the cases of two residents. Resident #4 was hospitalized twice in May 2024 for sepsis and a urinary tract infection (UTI), but the electronic health record (EHR) did not contain the necessary written bed hold notice for either hospitalization. Interviews with staff members revealed a lack of clarity regarding responsibility for completing the bed hold notice, with staff member E indicating that someone in administration was responsible, and staff member F unaware of any specific form associated with the bed hold process. Despite a request for resident #4's bed hold notices, none were provided by the end of the survey. Similarly, resident #47 was transferred to an acute hospital after a fall on August 3, 2024, but the facility did not provide a Notice of Bed Hold to the resident or their representative at the time of transfer. Staff member E confirmed that no notice had been provided by the nurse on the day of the transfer, reiterating that administration was responsible for this task. The facility's policy, dated December 19, 2016, stated that residents should be informed of the bed-hold policy upon admission and prior to transfer, with a representative of the business office or designee responsible for providing written information. However, this policy was not followed in the cases of residents #4 and #47.
Neglect Due to Denial of Re-entry After Hospital Discharge
Penalty
Summary
The facility failed to prevent neglect by denying a resident re-entry after he left the hospital against medical advice (AMA) and attempted to return. Despite an administrative directive to allow the resident to rest at the facility for the night, staff members did not follow through, resulting in the resident sitting outside in inclement weather for several hours. The resident, who was weak and had recently been diagnosed with cancer, was left in the rain and cold without a coat, which placed him at high risk of a serious adverse outcome. Staff members were aware of the resident's situation but failed to take appropriate action. Staff member D received a call from the hospital about the resident's return and contacted staff member C for guidance. Despite receiving instructions to allow the resident to stay, staff member D instructed the cab driver to take the resident back to the emergency room. Later, when a passerby and police officers informed the facility staff about the resident sitting outside, the staff continued to deny his entry, claiming he was discharged and needed physician orders to be readmitted. The facility staff's inaction and lack of concern were evident in their interactions with the police and the passerby. The staff did not assess or assist the resident, and no follow-up call was made to a provider for admission orders. The resident was eventually taken to the hospital by police, where he expressed a desire to return to the facility where his belongings were. The facility's failure to act on the administrative directive and their dismissive attitude towards the resident's well-being constituted neglect.
Failure to Timely Report Incidents and Investigation Findings
Penalty
Summary
The facility failed to report a significant event involving a resident who was denied reentry after leaving an acute hospital against medical advice. The resident was left outside the facility in a cab, and when the administration did not respond, the cab driver was instructed to take the resident back to the emergency room. Later, the resident was found sitting on a bench outside the facility, and the police were called. The police took the resident away, and the incident was not reported to the State Survey Agency in the required timeframe. Additionally, the facility did not report the findings of several incidents to the State Survey Agency within the mandated five-day timeframe. These incidents included allegations of falls with injury, resident-to-resident abuse, staff-to-resident abuse, and injuries of unknown origin. The delays in reporting ranged from five to twenty-three days. The facility's policy requires that the administrator or their designee report the results of all investigations within five working days, but this was not adhered to. Interviews with staff revealed that there was a miscommunication and lack of awareness regarding the reporting responsibilities, especially during a change in administration. Staff members admitted to not realizing the findings were not submitted on time and acknowledged their responsibility in the reporting process. The facility's policy outlines the procedure for reporting incidents, but it was not followed, leading to the deficiencies noted in the report.
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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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