Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Billings Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
Failure to notify the physician of a resident’s change in mental status occurred when a resident with schizophrenia and moderate cognitive impairment made repeated threats toward a roommate and staff. Staff separated the residents and monitored the situation, but did not contact the MD because they were unsure the behavior was a change from baseline; the resident was later involuntarily discharged after threatening others.
A resident with schizophrenia, schizoaffective disorder, bipolar type, depression, moderate cognitive impairment, and a history of violent behavior was involuntarily discharged after staff reported vague threats related to a roommate. Staff documented room changes, separation, monitoring, and psychiatric medication adjustment, but also stated there was no physician documentation supporting the discharge and no private room or 1:1 intervention was used. The resident’s representative said she could not care for the resident and that the home was unsafe, yet the resident was discharged there anyway after being told the alternative was jail.
A resident was admitted without a baseline care plan in place, and the medical record showed none was developed within the required 48 hours. A comprehensive care plan was not started until later, and an LPN stated she was not aware the resident lacked a baseline care plan even though one should have been in place.
Infection Control Lapse During Wound Care: A resident with a Stage III pressure ulcer to the left buttock was observed during wound care while feces was present on the buttocks and the resident was actively having a BM. After the wound was cleansed and a dressing applied, staff placed the dirty brief back on the resident and left the dirty bed pad under the resident before repositioning and covering her.
A resident at high risk for elopement with severe cognitive impairment exited the facility unattended and was later found by police and sent to the hospital for evaluation with no injuries. Surveyors later found multiple exit door alarm problems, including alarms that were too quiet, not sounding, or turned off, and staff interviews showed confusion about WanderGuard monitoring and alarm checks.
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.
Late Quarterly MDS Assessments: The facility failed to complete Quarterly MDS assessments within the required 14-day window after the ARD for 6 sampled residents. The MDS Coordinator stated he had recently started covering the role and believed some assessments were already late when he began, but he was unsure why they were overdue.
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’s Comprehensive MDS was completed late after the MDS Coordinator position had a coverage lapse and staff reported that several MDSs were already overdue when the new coordinator began covering. The resident’s admission MDS missed the required completion timeframe.
Failure to Float Heels and Reposition a Dependent Resident: A resident who was dependent on staff for help was repeatedly observed lying in bed with her heels resting on the bed or on a pillow instead of being floated, despite a care plan directing bilateral heel suspension boots and regular repositioning. The resident stated staff often forgot to keep her heels off the bed, and staff later noted her heels were boggy, with redness observed on her heels and back and swelling in her left arm and fingers.
Failure to fully investigate resident burn from hot soup: A resident spilled hot soup on himself and sustained burns, but the facility could not determine who provided the soup, whether a visitor accessed the locked nourishment room, or how the soup was heated. Video footage reviewed showed only a tall male visitor handing the resident a container, and no additional investigative documentation was found. The resident was later seen for follow-up for the burn wound, but the cause and supervision at the time of the incident were not clearly established.
Failure to Address Trauma History and Sexual Behaviors: A resident with moderate cognitive impairment, trauma/PTSD history, and stated interest in sexual intimacy had repeated inappropriate interactions with female residents, including entering rooms and inappropriate touching. The record did not show a completed sexual consent capacity assessment, a care plan addressing his trauma history or sexual behaviors, or behavior monitoring for those behaviors, and staff later documented the need for psych services after the behaviors were already occurring.
Medication administration errors exceeded the acceptable rate after staff gave a resident glucosamine chondroitin that did not match the MAR, applied Voltaren gel without measuring the ordered 2 gm dose, and identified a dose mismatch for another resident’s magnesium/calcium tablet. Staff noted the MAR and bottle discrepancies, and one LPN used ChatGPT rather than pharmacy to verify the dose.
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.
Failure to Notify Physician of Resident’s Threatening Behavioral Change
Penalty
Summary
The facility failed to ensure the physician was notified of a resident’s change in mental status when the resident made repeated threatening statements toward a roommate and staff. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and had a diagnosis of schizophrenia. On 5/16/26, the resident told staff that her roommate needed to be out of her room that night or something was going to happen. Staff member O did not ask follow-up questions or document the behavior, and the roommate was later moved to another room. Staff member O reported the resident appeared happy and pleasant on 5/17/26. On 5/18/26, the resident again told staff that if her roommate was not moved, something physical was going to happen, and later stated she needed to change rooms because her roommate was a bitch and was threatening the roommate. Staff member C stated the resident had a violent history and could only articulate that she was feeling agitated, but the facility did not contact the physician because staff were unsure whether the behaviors were a change from baseline. The facility contacted the psychiatrist on 5/18/26, and the resident was involuntarily discharged from the facility that evening for behaviors related to threatening others in the building.
Unsafe involuntary discharge without physician documentation
Penalty
Summary
The facility failed to ensure that an involuntarily discharged resident was discharged to a safe environment and failed to include physician documentation in the medical record describing the danger the resident posed by remaining in the facility, the interventions attempted, and efforts to meet the resident’s needs. The resident had diagnoses including anxiety disorder, schizoaffective disorder, bipolar type, depression, schizophrenia, and a history of alcohol dependence and violent behavior. The resident also had a BIMS score of 9, indicating moderate cognitive impairment, and the care plan identified behavioral symptoms, need for psychosocial support, and a discharge planning focus stating the resident would continue to stay in the facility due to inability to care for self outside that setting. Staff and records showed the resident made statements about a roommate and was moved to another room, after which the resident was described as grateful and repeatedly thanked staff. Staff later reported additional statements such as needing a roommate moved or “something physical is going to happen,” but staff also stated the resident did not directly threaten a specific resident and that the resident had been able to notify nurses when something was triggering her. Staff documented that the situation was de-escalated, roommates were separated, and the resident was monitored. One staff member stated the facility had not discussed a private room or used 1:1 staffing as an intervention, and another stated the resident’s medication doses were corrected to match home doses and a face-to-face psychiatric visit was scheduled. Despite these events, the resident was discharged the same day the concerns escalated. The resident’s representative stated she had told the facility she could not care for the resident and that the home was not safe because a tree had fallen on it and the roof was caving in. She also stated she was told the resident could go to jail or return home, and she refused to sign the discharge papers because she did not agree with the discharge and had not received prior notice of the behaviors. The discharge notice stated the resident was being discharged because the safety of individuals in the facility was endangered and that the resident posed an immediate danger, but the resident/representative signature line was not signed. Staff also stated the facility did not have physician documentation supporting the involuntary discharge, and the on-call physician was not notified until after the resident had already discharged.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to initiate and implement a baseline care plan for 1 of 17 sampled residents. Resident #1 was admitted on [DATE], and the medical record lacked a baseline care plan. A comprehensive care plan was not initiated until 5/18/26. During an interview on 5/20/26 at 3:28 p.m., staff member C stated she was not aware that resident #1 did not have a baseline care plan and stated that resident #1 should have had one in place. The facility policy, Baseline Care Plan, dated 4/4/26, stated that the facility will develop and implement a baseline care plan for each resident and that it will be developed within 48 hours of admission.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to ensure infection control processes were followed during wound care for a resident with a Stage III pressure ulcer to the left buttock. During an observation and interview, staff member T opened the resident’s brief on the left side while the resident had dried feces on the lower left side of the buttocks and had actively started to have a bowel movement. Staff member T cleaned the feces, cleansed the Stage III pressure wound with Vaish cleanser, and NF3 applied a dressing. After NF3 left the room, staff member T requested staff member Q to assist with repositioning the resident after wound care. Staff member T and staff member Q then placed the dirty brief back on the resident after the dressing change and left the dirty bed pad under the resident before positioning her and covering her with blankets. During interview, staff member T stated, “I wasn't even thinking. We put the dirty brief back on her. We will go back and change her (resident #15). I didn't even think.”
Elopement Prevention and Door Alarm Failures
Penalty
Summary
The facility failed to ensure that a resident at high risk for elopement was supervised and that exit doors were secured. Resident #5 had a WanderGuard device in place and a BIMS score of 7, indicating severe cognitive impairment. A facility investigation showed the resident exited the facility unattended on 4/16/26 at approximately 10:00 a.m., was located by police the next day, and was transported to the hospital for evaluation with no injuries found. The facility’s root cause analysis identified the elopement as resulting from a staff member’s failure to follow facility policies and procedures related to elopement prevention, resident supervision, and WanderGuard monitoring. During later observations, several exit doors were found with alarm problems: one hall exit alarm sounded so quietly it could not be heard, an activities/no smoking exit door did not sound when tested with a WanderGuard, and a dining room screamer alarm was turned off. Staff interviews showed confusion about checking alarms, including reliance on indicator lights rather than sound, and that some alarm-checking tasks had dropped off the work order system. Testing also showed two residents’ WanderGuard bracelets did not work with the tester box, and a resident was observed entering and remaining in the dark dining room before exiting through a door with the screamer alarm off.
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.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete Quarterly MDS assessments within the required timeframe of 14 days after the ARD for 6 of 25 sampled resident assessments. During an interview, the MDS Coordinator stated he began covering the role at the end of December 2025 and believed the facility already had Quarterly MDS assessments that were late when he started, but he was not sure why they were late. Record review showed that resident #11’s Quarterly MDS with an ARD of 12/18/25 was due by 1/1/26 but was completed on 1/8/26. Resident #55’s Quarterly MDS with an ARD of 12/23/25 was due by 1/6/26 but was completed on 1/8/26. Resident #7’s Quarterly MDS with an ARD of 1/1/26 was due by 1/15/26 but was completed on 1/19/26. Resident #5’s Quarterly MDS with an ARD of 1/9/26 was due by 1/23/26 but was completed on 2/2/26. Resident #10’s Quarterly MDS with an ARD of 1/15/26 was due by 1/29/26 but was completed on 2/2/26. Resident #9’s Quarterly MDS with an ARD of 1/19/26 was due by 2/2/26 but was completed on 2/4/26.
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.
Late Comprehensive MDS Completion
Penalty
Summary
The facility failed to complete a Comprehensive MDS assessment within the required timeframe for resident #67. The resident was admitted on 1/8/26, and an admission MDS was scheduled with an ARD of 1/14/26, making the MDS due by 1/21/26; however, it was completed late on 1/22/26. During interviews, staff member A stated the previous MDS Coordinator left in late November or early December 2025 and there was a lapse in coverage before the current MDS Coordinator started, which may have contributed to late MDS completion. Staff member M stated he began covering as the MDS Coordinator at the end of December 2025 and believed there were MDSs that were late when he started, but he was not sure why they were late.
Failure to Float Heels and Reposition a Dependent Resident
Penalty
Summary
The facility failed to follow resident #79’s individualized care plan for repositioning and heel elevation to prevent skin breakdown. During multiple observations, the resident was found lying flat on her back with a pillow beneath her legs, but her heels and feet were still touching the bed or resting on the pillow’s surface rather than being floated. The resident stated she was never repositioned by staff, that she lay flat on her back very frequently, and that staff were supposed to keep her heels from touching the bed but often forgot to do so. Resident #79 stated she was dependent on staff for help and would rarely get out of bed for activities. On a later observation, staff member L stated the resident’s heels were boggy, and the resident’s heels were observed to be slightly red, her entire back was red, and her left arm and fingers were noticeably swollen. The care plan, initiated 7/15/25, directed staff to use bilateral heel suspension boots to float the heels while in bed and to assist the resident to turn and reposition regularly to offload pressure points, but the boots were not observed when the resident was in bed.
Failure to fully investigate resident burn from hot soup
Penalty
Summary
The facility failed to thoroughly investigate an accidental burn involving a resident who spilled hot soup on himself. Staff member B stated the resident sustained the burn on 10/30/25, and that a review of surveillance footage showed only a tall male visitor in street clothes handing the resident a container. However, no additional investigative documentation was found to determine who provided the hot soup, whether the visitor accessed the nourishment room, or how the soup was heated. Staff member B also stated the burn was determined not reportable based on the footage reviewed, despite the lack of a clear determination of how the incident occurred. Staff member E stated the microwave used to heat resident food was located inside a locked nourishment room and that staff were expected to obtain and document food temperatures when heating food for residents. She treated the resident's wound but did not know how the injury occurred. Staff member A stated the facility's video surveillance was overwritten about every two weeks, and the facility was unable to retrieve or review the footage from the incident when the concern was identified three weeks later. Review of the physician note showed the resident was seen for follow-up after nursing staff reported a burn wound from hot soup, and the resident nodded yes when asked if he had dropped hot soup on himself. Facility records contained no documented determination of whether the visitor accessed the locked nourishment room, whether staff heated the soup, whether the soup entered the facility already hot, or whether supervision at the time of the incident was adequate.
Failure to Address Trauma History and Sexual Behaviors
Penalty
Summary
The facility failed to develop an individualized care plan for a resident with a history of trauma and psychosocial concerns, including trauma/PTSD, substance abuse, behavioral issues, self-efficacy deficits, lack of coping skills, and a stated desire for physical/sexual intimacy while in the facility. The resident had a BIMS score of 9, indicating moderate cognitive impairment, with some confusion and forgetfulness but the ability to communicate needs and follow conversation. The psychosocial assessment also indicated that the resident expressed a desire to engage in sexual activity with others and required a Sexual Activity Capacity to Consent Assessment, but that assessment was not found in the medical record. The resident’s record showed multiple references to sexualized or inappropriate behavior. A social services note documented that the resident said he was engaged to another resident, and staff planned to monitor for increased behaviors related to that statement. A behavior progress note stated 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. Another social services note described the resident reporting plans to marry another resident in the facility, with management later determining the wedding could not take place. The facility also did not timely identify the need for additional mental health trauma-based services. The resident’s care plan did not reflect his past trauma history or potential for sexual behaviors, and the record did not show behavior monitoring for those behaviors from admission through the survey date. A psychiatric evaluation completed later documented inappropriate sexual behaviors in the facility, including entering female residents’ rooms and inappropriate touching, with frequent staff redirection. Staff interviews confirmed that the Sexual Activity Capacity to Consent Assessment was not completed and that the resident and the other involved resident were not capable of providing sexual consent due to cognition.
Medication Error Rate Exceeded Threshold
Penalty
Summary
Medication administration errors exceeded the acceptable threshold, with a calculated error rate of 10.34%. During observation and record review, staff prepared morning medications for resident #14 and noted that the MAR and the medication bottle for glucosamine chondroitin did not match. The bottle was half empty, and staff stated the medication had most likely been given previously. The bottle listed Glucosamine Chondroitin Complex containing Vitamin C 30 mg, Manganese 2.5 mg, Sodium 20 mg, Potassium 28 mg, Glucosamine Sulfate 250 mg, and Chondroitin Sulfate 200 mg, while the MAR did not show any other substances ordered by the physician. The resident’s EHR showed an order for Glucosamine-Chondroitin Oral Tablet 250-200 MG. For resident #14, staff also administered diclofenac sodium external gel (Voltaren gel) by squeezing approximately one tablespoon into gloved hands and rubbing it onto both knees without measuring the ordered dose. The EHR showed an order to apply 2 gm to both knees 3 times a day. For resident #51, staff preparing morning medications identified that the magnesium chloride with calcium bottle did not match the MAR dose. The bottle listed a serving size of two tablets with calcium 238 mg and magnesium 143 mg, while staff calculated one tablet as calcium 119 mg and magnesium 71.5 mg. Staff stated the dose did not match up and that pharmacy was not contacted; instead, ChatGPT was used to verify whether the dose was correct. The resident’s EHR showed an order for Slow magnesium/calcium oral tablet delayed release 70-117 mg.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Billings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yellowstone River Nursing And Rehabilitation | 3.4 mi | ★★★★★ | 37 | 0 |
| River Ridge Rehabilitation And Nursing Llc | 3.8 mi | ★★★★★ | 29 | 0 |
| Skyline Heights Nursing And Rehabilitation | 4 mi | ★★★★★ | 22 | 1 |
| Aspen Meadows Health And Rehabilitation Center | 4.4 mi | ★★★★★ | 23 | 0 |
| St John's Lutheran Home | 6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.